Medicinal vaginal lactobacillus cocktail

ABSTRACT

Described herein are methods and compositions for the use of treating and/or preventing vaginal bacterial infection and promoting healthy vaginal flora. Aspects of the invention relate to administering to a subject in need thereof a composition comprising a bacterial mixture of L. crispatus, L. gasseri, and L. jensenii.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Application is a 35 U.S.C. 371 National Phase Entry Application of International Application No. PCT/US2017/041558 filed Jul. 11, 2017, which designates the U.S. and claims benefit under 35 U.S.C. § 119(e) of the U.S. Provisional Application No. 62/360,535 filed Jul. 11, 2016, the contents of which are incorporated herein by reference in their entireties.

GOVERNMENT SUPPORT

This invention was made with Government support under Grant Nos. R33 AI094508 awarded by the National Institutes of Health. The Government has certain rights in the invention.

FIELD OF THE INVENTION

The field of the invention relates to the establishment or promotion of a healthy flora.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. Said ASCII copy, created on Dec. 6, 2018, is named 043214-089901-PCT_SL.txt and is 39,330 bytes in size.

BACKGROUND

An overwhelming body of epidemiologic evidence demonstrates that the resident vaginal bacteria are tightly interwoven into the fabric of innate immunity in the female genital tract, with major consequences for women's and infants' health. It is well supported by culture-based and genomic-based studies that Lactobacilli are the resident vaginotropic bacteria dominating the healthy vaginal microbiome. The state of bacteriome disturbance (vaginal dysbiosis) can lead to vaginitis, bacterial translocation or bacterial vaginosis (BV), which is the most common morbid microbiological syndrome among women of childbearing age, characterized by a shift from a Lactobacillus-dominated bacteriome to more diverse polymicrobial states with abundant Prevotella, Atopobium, Gardnerella and other less characterized anaerobes (Onderdonk et al., 2016). BV is associated with adverse pregnancy outcome, e.g. preterm birth, sexually transmitted infections and higher risk of HIV acquisition, cervicovaginal viral shedding and transmission (Onderdonk et al., 2016, Buve et al., 2014). Antibiotic treatment is often ineffective to cure and prevent frequent relapses of BV, and even capable of worsening reproductive outcome.

SUMMARY

The compositions and methods described herein are based, in part, on the discovery that a bacterial mixture comprising viable Lactobacillus species results in synergistic effects that are effective in treating and/or preventing BV and promoting a healthy vaginal flora. The species that result in this synergistic effect include Lactobacillus species, Lactobacillus crispatus (L crispatus). Lactobacillus gasseri (L. gasseri), and Lactobacillus jensenii (L. jensenii). The selected species are isolated from human subjects and are not proinflammatory. It was also discovered in the course of this work that the proportions of Lactobacillus species in the bacterial mixture used to treat and/or prevent BV are important for the efficacy of the treatment.

In one aspect, provided herein is a cocktail comprising Lactobacillus species including L. crispatus, L. jensenii and L. gasseri. In some embodiments, the only Lactobacillus species in the cocktail are L. crispatus, L jensenii and L. gasseri. In some embodiments, the L. crispatus strain in the composition is 223310. In some embodiments, the L. jensenii strain in the composition is 2054210. In some embodiments, the L. gasseri strain in the composition is 29313. In some embodiments, the Lactobacilli in the composition are L. crispatus strain 223310, L. jensenii strain 2054210, and L. gasseri strain 29313.

In some embodiments, L. crispatus comprises 50-73.3% of the bacterial mixture, L. jensenii comprises 6.67-33.4% of the bacterial mixture, and L. gasseri comprises 16.7-33.4% of the bacterial mixture.

In some embodiments, the bacterial mixture is comprised of 66.7% L. crispatus, 16.7% L. jensenii, and 16.7% L. gasseri.

In some embodiments, the bacterial mixture is comprised of 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri.

In some embodiments, the bacterial mixture is comprised of 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri.

In one embodiment, the bacterial mixture further comprises an agent that promotes bacterial growth. Non-limiting example of an agent that promotes bacterial growth include boric acid, a prebiotic, lactic acid, ascorbic acid or another low pH buffering agent.

In one embodiment, the bacterial mixture further comprises an anti-microbial agent or preparation. Non-limiting examples of an anti-microbial agent or preparation include recombinant proteins e.g. human soluble serine leukocyte protease inhibitor (SLPI), which is significantly reduced by BV bacteria and Trichomonas vaginalis and deficient in the vaginal secretions of women with BV and trichomoniasis (Huppert et al., 2013), synthetic small molecules e.g. purine analogs e.g. 9-(2-deoxy-2-fluoro-β-Darabinofuranosyl) adenine.

In one embodiment, the bacterial mixture further comprises an antibiotic. In another embodiment, the bacterial mixture further comprises an antibiotic against sexually transmitted and reproductive tract infections including but not limited to bacterial vaginosis, Chlamydia, Candida and Trichomonas vaginalis.

In one embodiment, the antibiotic is metronidazole. In another one embodiment, the antibiotic is clindamycin.

In some embodiments, the bacterial mixture does not elicit an inflammatory response in the subject receiving the treatment.

In some embodiments, the bacterial mixture does not comprise Lactobacillus rhamnosus.

In one embodiment, the bacterial mixture is formulated for vaginal delivery.

In another embodiment, the bacteria are in a dried form.

In another embodiment, the bacteria mixture further comprises one or more protective excipients. Non-limiting examples of a protective excipient includes a nonreducing monosaccharide, sugar alcohol, oligosaccharide, amino acid, polyvinylpyrrolodone, polyethylene glycol, Ficol, inulin, albumin, gelatin, whey proteins, and a polaxomer.

In one embodiment, the bacteria mixture is in a glassy matrix.

In one embodiment, the bacterial mixture is stable at room temperature for at least one year.

Another aspect of the invention relates to the method for treating vaginal dysbiosis by administering the bacterial mixture disclosed herein by administering the mixture to a subject having, or at risk of having, a vaginal bacterial infection.

In one embodiment, the vaginal infection is caused by the vaginal pathogen Trichomonas vaginalis.

In one embodiment, the vaginal bacterial infection is caused by the vaginal pathogen Gardnerella vaginalis.

In one embodiment, the vaginal bacterial infection is caused by the vaginal pathogen Prevotella bivia.

In one embodiment, the vaginal bacterial infection is caused by the vaginal pathogen Atopobium vaginae.

In one embodiment the subject is not pregnant. In another embodiment, the subject is pregnant.

In one embodiment the bacterial mixture is delivered to a subject vaginally.

In another embodiment, the bacterial mixture is delivered to a subject as vulvo-vestibular cream.

In another embodiment, the bacterial mixture is delivered to a subject orally.

In another embodiment, the bacterial mixture is delivered to a subject rectally.

In one embodiment, the bacterial mixture restores a healthy vaginal flora.

Another aspect described herein relates to a method of isolating a bacterial strain useful in the treatment of a vaginal bacterial infection. The method comprises (i) isolating bacteria from the vagina of a healthy woman; (ii) isolating Lactobacillus species from the bacteria isolated in step (i) via phenotypic and genetic analysis; (iii) verifying stable colonization of Lactobacillus species isolated in step (ii) in human vaginal epithelium; (iv) verifying that isolated Lactobacillus species isolated in step (ii) do not elicit an immune response (v) verifying minimal mutual antagonism with isolated Lactobacillus species isolated in step (ii); and (vi) verifying colonization of Lactobacillus species isolated in step (ii) in human vaginal epithelium in the presence of a vaginal pathogen; (viii) generating synergistic formulas comprising of select organisms that past selection criteria in all of the above steps.

In one embodiment, the method further comprises assessing in vitro antimicrobial properties of isolated Lactobacillus species.

In one embodiment, the bacteria are isolated from a healthy pregnant woman. In another embodiment, the healthy pregnant woman gives birth at 38-40 weeks of gestation.

Definitions

As referred to herein, the term “healthy human vaginal microbiota balance” refers to the population of different microbial species colonizing or inhabiting the human vagina or vaginal epithelium that together provide an environment that discourages the growth of pathogenic microbes and is not proinflammatory. A healthy human vaginal microbiota balance includes a variety of microbial species in which the relative numbers of each species are in homeostasis. In one embodiment, homeostasis, when used in this context, means that the relative abundance of each species in a population remains generally static, e.g. detectable in the same quartile of multiple logarithmically transformed counts taken over a period of time (for example over several menstrual cycles in a reproductive age women or over a pregnancy trimester), relative to other species in the population. Among healthy reproductive age women the frequency of detection of Lactobacillus species across a menstrual cycle varied by less than 2SD (<3%) and the colony forming counts varied also by less than 2SD (˜one log₁₀ CFU per gram)(Onderdonk et al., 1987). In one embodiment, “homeostatic”, when used in this context, refers to resistant to perturbations caused by vaginal pathogens, e.g. persistence of the colony forming units of healthy bacteria associated with the vaginal epithelium at the time of or after infection by vaginal pathogens.

The healthy human vaginal microbiota is dominated by specific homeostatic Lactobacillus species (can be about 95%) L. crispatus, L. gasser and L. jensenii, which play an essential role in maintaining an environment that discourages urogenital infection. Species of Lactobacilli adapted to the healthy vaginal environment (but not all Lactobacillus species) have the ability to adhere to vaginal epithelia, to inhibit the adhesion and growth of pathogens and to deplete nutrients that otherwise permit the growth of pathogens. Such species also modulate the host's immune response, generally maintaining or promoting a non-proinflammatory status. A critical function of vaginal Lactobacilli is to metabolize glycogen produced by vaginal epithelial cells to produce lactic acid. In a healthy vagina, pH-values of 4.0-4.5 are reached; at this pH, many pathogens cannot flourish. The production of H₂O₂ is another feature distinguishing mostly beneficial from mostly non-beneficial Lactobacillus species and essential for anti-viral properties such as anti-HIV activity of vaginal lactobacilli (Klebanoff and Coombs, 1991). H₂O₂ producing lactobacilli are present in the vagina of most normal healthy women, but they are absent from most women with BV (Klebanoff and Coombs, 1991). Therefore we included H₂O₂ production in our Lactobacillus strain selection algorithm.

By contrast, a “dysbiotic” human vaginal microbiota balance refers to a population of vaginal microbes that promotes inflammation of a tissue of the vagina and/or that contributes to or establishes an environment that permits or promotes the colonization or growth of one or more pathogenic microbes. A dysbiotic vaginal microbiota will generally result in increased pH relative to a healthy microbiota, e.g., a pH above 5.0, e.g, a pH of 5.5, 5.7, 6.0, 6.2, 6.5, 6.7, 7.0 or higher. In one embodiment, “dysbiosis” when used in this context, refers to a perturbation of the vaginal homeostasis where Lactobacillus species colony forming units are displaced from the vaginal epithelium or reduced after infection by vaginal pathogens compared to colony forming units enumerated before infection.

The term “probiotic” as used herein refers to “live microorganisms, which when administered in adequate amounts confer a health benefit on a host” (FAO 2001: see the website at isapp.net/docs/ProbioticDefinition.pdf).

As used herein, the term “proinflammatory” refers to a status in which expression or accumulation of one or more markers or mediators of inflammation, e.g., inflammatory chemokines e.g., IL-8, MIP-1α, MIP-2α, MIP-1β, or inflammatory cytokines, e.g., TNF-α, IL-1 and/or IL-6, are induced in host tissue (Fichorova, 2004, Doncel et al., 2004, Fichorova et al., 2004). A proinflammatory status is also evidenced by the accumulation of inflammatory cells such as polynuclear neutrophils (PNN) and/or eosinophils, among others, in host tissues (Doncel et al., 2004, Fichorova et al., 2004).

As used herein, the term “full term pregnancy,” for humans, refers to a pregnancy in which delivery of a healthy infant occurs at 38-40 weeks of gestation. The American College of Obstetricians and Gynecologists applies the following definitions as of 2013: 1) Early Term is between 37 weeks and 38 weeks 6 days; 2) Full Term, between 39 weeks and 40 weeks 6 days; 3) Late Term, the 41st week; 4) Post Term, after 42 weeks.

As used herein, the term “stable colonization” refers to the colonization of an environment, e.g., the vagina or vaginal epithelium, by a microbe, e.g., a bacterium, such that the viable population of that microbe continues over time. A stably colonizing population will generally remain substantially static once colonization is complete, e.g. logarithmically transformed colony forming units associated with the vaginal epithelial tissue will remain in the same quartile after the initial period of colonization (complete in 4 h at the cellular level) when followed within the lifespan of the vaginal epithelial cells (24-48 h).

As used herein, the term “does not elicit an immune response,” and equivalent terms “does not induce an immune response” and “does not promote an immune response” or similar variations thereof mean that a given microbial species, e.g., a bacterial species, does not substantially induce inflammatory response by the host immune system. A microbe that does not induce an immune response will not, when administered to human vaginal cells, the vagina of a human or a test animal, promote an expression or accumulation of inflammatory chemokines or cytokines, to significantly increase levels above those of a the healthy unperturbed baseline or the recruitment or accumulation of inflammatory host cells.

The terms “increased”, “increase”, “enhance”, or “activate” are all used herein to mean an increase by a statically significant amount. In some embodiments, the terms “increased”, “increase”, “enhance”, or “activate” can mean an increase of at least 10% as compared to a reference level, for example an increase of at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% increase or any increase between 10-100% as compared to a reference level, or at least about a 2-fold, or at least about a 3-fold, or at least about a 4-fold, or at least about a 5-fold or at least about a 10-fold increase, or any increase between 2-fold and 10-fold or greater as compared to a reference level. In the context of a marker or symptom, an “increase” is a statistically significant increase in such level.

The terms “lower”, “reduced”, “reduction” or “decrease”, “down-regulate” or “inhibit” are all used herein generally to mean a decrease by a statistically significant amount. However, for avoidance of doubt, “lower”, “reduced”, “reduction” or “decrease” or “inhibit” means a decrease by at least 10% as compared to a reference level, for example a decrease by at least about 20%, or at least about 30%, or at least about 40%, or at least about 50%, or at least about 60%, or at least about 70%, or at least about 80%, or at least about 90% or up to and including a 100% decrease (i.e. absent level as compared to a reference sample), or any decrease between 10-100% as compared to a reference level.

The terms “statistically significant” or “significantly” refer to statistical significance and generally means a two standard deviation (2SD) or greater difference.

As used herein, a “subject” means a human or animal. Usually the animal is a vertebrate such as a primate, rodent, domestic animal or game animal. Primates include chimpanzees, cynomologous monkeys, spider monkeys, and macaques, e.g., Rhesus. Rodents include mice, rats, woodchucks, ferrets, rabbits and hamsters. Domestic and game animals include cows, horses, pigs, deer, bison, buffalo, feline species, e.g., domestic cat, canine species, e.g., dog, fox or wolf. In some embodiments, the subject is a mammal, e.g., a primate, e.g., a human. The terms, “individual,” “patient” and “subject” are used interchangeably herein. Mammals other than humans can be advantageously used as subjects that provide animal models of the vaginal environment. A subject as the term is used herein is generally female.

Other than in the operating examples, or where otherwise indicated, all numbers expressing quantities of ingredients or reaction conditions used herein should be understood as modified in all instances by the term “about.” The term “about” when used in connection with percentages can mean±1%.

As used herein, the terms “treat,” “treatment,” “treating,” or “amelioration” refer to therapeutic treatments, wherein the object is to reverse, alleviate, ameliorate, inhibit, slow down or stop the progression or severity of a condition associated with a disease or disorder. The term “treating” includes reducing or alleviating at least one adverse effect or symptom of a condition, disease or disorder, for example vaginal infection, e.g., bacterial vaginosis or fungal vaginitis. Treatment is generally “effective” if one or more symptoms or clinical markers are reduced. Alternatively, treatment is “effective” if the progression of a disease is reduced or halted. That is, “treatment” includes not just the improvement of symptoms or markers, but can also include a cessation or at least slowing of progress or worsening of symptoms that would be expected in absence of treatment. Beneficial or desired clinical results include, but are not limited to, alleviation of one or more symptom(s) of a disease or disorder, diminishment of extent of a disease or disorder, stabilized (i.e., not worsening) state of a disease or disorder, delay or slowing of progression of a disease or disorder, amelioration or palliation of the disease or disorder state, and remission (whether partial or total), whether detectable or undetectable. The term “treatment” of a disease or disorder also includes providing relief from the symptoms or side-effects of the disease (including palliative treatment). Treatment for an infection can, but does not necessarily, include 100% eradication of the pathogen—a treatment that reduces the level of a pathogen to one which is kept in check by the immune system or by the state established by a healthy vaginal micorbiota is considered effective as the term is used herein.

As used herein, the term “pharmaceutical composition” refers to the active agent in combination with a pharmaceutically acceptable carrier e.g. a carrier commonly used in the pharmaceutical industry. The phrase “pharmaceutically acceptable” is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio. In some embodiments of any of the aspects, a pharmaceutically acceptable carrier can be a carrier other than water. In some embodiments of any of the aspects, a pharmaceutically acceptable carrier can be a cream, emulsion, gel, liposome, nanoparticle, film, ointment and/or vaginal device e.g. vaginal ring. In some embodiments of any of the aspects, a pharmaceutically acceptable carrier can be an artificial or engineered carrier, e.g., a carrier that the active ingredient would not be found to occur in nature.

The phrase “pharmaceutically acceptable carrier” as used herein means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent or encapsulating material that maintains a drug or other agent in a form for delivery to a subject. Each carrier must be “acceptable” in the sense of being compatible with the other ingredients of the formulation, for example the carrier does not decrease the impact of an active ingredient or agent upon the treatment. In other words, a carrier is pharmaceutically inert. The terms “physiologically tolerable carriers” and “biocompatible delivery vehicles” are used interchangeably.

The terms “administered” and “subjected” are used interchangeably in the context of treatment of a disease or disorder. Both terms refer to a subject being treated with an effective dose of pharmaceutical composition comprising a composition as described herein by methods that deliver the composition, e.g., a probiotic cocktail, to the vagina.

The term “optional” or “optionally” means that the subsequent described event, circumstance or substituent may or may not occur, and that the description includes instances where the event or circumstance occurs and instances where it does not.

As used herein, the term “comprising” means that other elements can also be present in addition to the defined elements presented. The use of “comprising” indicates inclusion rather than limitation. The term “consisting of” refers to compositions, methods, and respective components thereof as described herein, which are exclusive of any element not recited in that description of the embodiment. As used herein the term “consisting essentially of” refers to those elements required for a given embodiment. The term permits the presence of elements that do not materially affect the basic and novel or functional characteristic(s) of that embodiment of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows that the manisfestation of the indicated diseases increases with the number of elevated inflammatory proteins present in the infant at birth (odd ratios>1).

FIG. 2 shows the mediators of inflammation found to be increased (odds ratios>1) in the systemic circulation of infants born to mothers with cervicitis and vaginitis.

FIG. 3 shows the mediators of inflammation found to be increased (odds ratios>1) in the systemic circulation of infants born to mothers with bacterial vaginosis.

FIG. 4 shows the presence of inflammation mediators found to be increased in the systemic circulation of infants born to mothers with the indicate microorganism present in the placenta.

FIG. 5 shows genomic studies of the vaginal microbiota typically associated with non-BV Nugent score and those typically associated with a BV Nugent score.

FIG. 6 illustrates the relationship between dysbiotic vaginal bacteria and mediators of inflammation. In Caucasian women with unstable vaginal microbiota followed in 4 weekly intervals, increased counts of a non-homeostatic Lactobacillus species (L. iners) coincide with peaks in numbers of the BV bacteria A. vaginae and G. vaginalis and when that happens proinflammatory cytokines and chemokines are also at a peak.

FIGS. 7A and 7B show the vaginal micobiota community states from reproductive age African women. (FIG. 7A) Next generation sequencing data show the most abundant bacteria clustered in 4 cervicovaginal community types (CT) (FIG. 7B) Comparing a NextGen-derived community state type dominated by L. crispatus (CT1) to that dominated by L. iners (CT2) and to that of BV-dominant bacteria e.g. A. vaginae and G. vaginalis (CT3) or A. vaginae. G. vaginalis and P. bivia (CT4) clearly showed that in African women just as in Caucasian women (FIG. 6) (see e.g., Kyongo J K, Jespers V, Goovaerts O, et al. PloS one. 2012) L. crispatus is superior to L. iners since CT2 was associated with a tendency of higher levels of inflammatory cytokines compared to CT1, and similar to CT3 and CT4.

FIGS. 8A-8E shows inflammatory proteins from groups in FIG. 7B. The level of (FIG. 8A) IL-1α, (FIG. 8B) IL-1β, (FIG. 8C) TNF-α, (FIG. 8D) INF-γ, and (FIG. 8E) IL-12p70 were measured.

FIGS. 9A-9H show colonization of human vaginal and cervical epithelial cells by vaginal bacteria characterized by a consistent bacterial association with epithelial cells in the absence of apoptosis and cell toxicity. (FIGS. 9A-9D) Transmission electron microscopy image showing L. crispatus (FIGS. 9A and 9B) and P. bivia (FIGS. 9C and 9D) bacteria, visualized as electron-dense bodies, adherent to the surface of vaginal epitheliai cells (Vk2/E6E7), which exhibit intact morphology after 24 h of colonization. The bars and images represent 500 nm and ×4,800 magnification (FIG. 9A), 500 nm and ×6,800 magnification (FIG. 9B), 2 μm and x 1,900 magnification (FIG. 9C), and 500 nm and ×13,000 magnification, respectively. (FIG. 9E) Caspase-3 cleavage is presented as percentages of cleaved from total caspase-3 measured in vaginal epithelial cell lysates at 24 h after bacterial colonization or treatment with 1 μM staurosporine. Bars represent means and standard errors of the means (SEM) of the results determined with duplicate cultures used in two experiments. (FIG. 9F) Viability of vaginal epithelial cells assessed by trypan blue inclusion tests at 5 days postcolonization. Bars represent means and SEM of the results from triplicate culture experiments. (FIG. 9G) CFU counts per square centimeter of epithelial cell surface at 24 h and 48 h postcolonization of Vk2/E6E7 cells. Bars represent means and SEM of the results determined with triplicate cultures used in three experiments. (FIG. 9H) Parallel assessment of CFU counts associated with primary polarized (VEC-100) and immortalized monolayer (Ect1/E6E7) ectocervical epithelial cells at 48 h postcolonization.

FIG. 10 shows the colonization rate on agar for the microbes alone or in combination. When seeded alone on agar, the individual lactobacilli grew comparably in the presence or absence of BV-signature bacterium A. vaginae and even suppressed the growth of A. vaginae on agar. LG=L. gasseri, LC=L. crispatus, and AV=A. vaginae.

FIG. 11 shows the colonization rate on epithelial cells for the microbes alone or in combination. When allowed to colonize epithelial cells, L. gasseri but not L. crispatus maintained viable colony forming units in the presence of A. vaginae and L. gasseri but not L. crispatus suppressed the epithelial colonization by A. vaginae. LG=L. gasseri, LC=L. crispatus, and AV=A. vaginae.

FIG. 12 shows that the effectiveness of individual microbes in treating infected T. vaginalis vaginal epithelium. T. vaginalis infection, which is the most common non-viral sexually transmitted pathogen and the most common cause of vaginitis, is associated with vaginal dysbiosis and frequently co-occurs with BV. When tested individually, L. jensenii was shown to be most resistant to the suppressive effects of T. vaginalis.

FIGS. 13A-13D. Shows differences between Lactobacillus strains indicated by the activity of the indicated inflammation mediator with the indicated strains and activity against G. vaginalis. Individual vaginal lactobacillus strains differed in their immune profiles assessed by cytokines and chemokine production by human vaginal and cervical epithelial cells 24 h after bacterial colonization (FIGS. 13A-13C) and also differed by theri anti-BV activities assessed by G. vaginalis colonization rates (FIG. 13D). Among 5 BWH strains selected based on favorable pregnancy outcome, three representing L. crispatus (Lc1), L. jensenii (Lj1) and L. gasseri (Lg) (bars in black) were further selected based on: 1) their best homeostatic properties e.g. cytokine levels (exemplified by IL-8, FIG. 13C) closest to the epithelial baseline (CTRL); 2) activity against G. vaginalis (FIG. 13D). The Lc strains obtained from S. Hiller (Lc4) failed due to highest pro-inflammatory activity compared to the others and the ATCC prototype (Lj3) failed due to lack of anti-G. vaginalis activity (FIG. 13B).

FIGS. 14A-14C shows a molecular analysis confirming species identity of isolated strains: (FIG. A). L. crispatus, (FIG. B). L. jensenii, (FIG. C) L. gasseri.

FIG. 15. Shows genome alignment of the three selected strains and known genomes. BLASTN search identified that the three sequenced genomes (Lc-=L crispatus 223310, Lj=L. jensenii 2054210, and Lg=L. gasseri 293-13) are quite divergent from each other, sharing less than about 80% nucleotide sequence identity.

FIGS. 16A and 16B shows reproducible colonization activity of the three selected Lactobacillus strains (Lc-=L crispatus 223310, Lj=L. jensenii 2054210, and Lg=L gasseri 29313). A steady recovery of colony forming units (CFU) from human vaginal (FIG. 16A) and ectocervical (FIG. 16B) epithelial cells was achieved upon 24 h exposure to the three selected strains in the absence of epithelial toxicity measured by no increase in cleaved caspase-3 and lack of change in total caspase levels by comparison to non-infected baseline and cells stimulated with pro-apoptotic agents e.g. staurosporin and a viral mimic poly(I:C) (FIG. 16B)

FIG. 17 shows the growth proportions of the indicated bacteria when colonized at differing ratios. The strains were applied at a total concentration of 7×10⁶/ml (FIG. 17A) and later optimized to a total initial concentration of 7×10⁵/ml (FIG. 17B) which resulted in a synergistic growth that exceeded total Lactobacillus colonization when the individual bacteria were applied alone at the same concentration. Based on these results formulas 2 and 4 were excluded from further testing). The bars represent duplicate cultures (mean and SEM) in at least 3 experiments with each formula tested side by side. (Lc-=L. crispatus 223310, Lj=L. jensenii 2054210, and Lg=L. gasseri 29313).

FIG. 18 shows the benefit of using a 3-strain formula in treating infected T. vaginalis vaginal epithelium. An unexpected finding was that when the infection was conducted in vaginal epithelium colonized with the 3-strain mix, the cumulative Lactobacillus colonization rate was higher compared to that of most individual strains, demonstrating resistance to the microbiome perturbations by T. vaginalis.

FIGS. 19A-19C shows the colonization benefit of combining the 3 select strains in terms of better survival in the presence of BV signature bacterium A. vaginae, P. vivia, and G. vaginalis. Mixing the three selected strains L. crispatus 223310 (Lc), L. jensenii 2054210 (Lj) and L. gasseri 29313 (Lg) in an optimized mix formula resulted in about 2-fold better cumulative Lactobacillus colonization rate in the presence of A. vaginae (FIG. 19A) or P. bivia (FIG. 19B) compared to the same strains applied individually, and a better preservation of colonization by each individual Lactobacillus strain in the mix compared to an equal proportion 1:1:1 demonstrating a clear benefit and indication for using the optimal mix formula for restoring the healthy Lactobacillus-dominated microflora in patients with BV. All 3-strain mixes resulted in a better Lactobacillus colonization compared to individual strains in the presence of G. vaginalis (FIG. 19C).

FIG. 20 shows reproducible colonization of bioengineered human cervicovaginal tissue (VEC100) by the three selected Lactobacillus strains (Lc-=L. crispatus 223310, Lj=L. jensenii 2054210, and Lg=L. gasseri 29313) and an improved synergistic colonization by the 3-strain formulas indicated.

FIG. 21 shows the number of L. crispatus, L. jensenii, and L. gasseri CFU following colonization with BBC alone or with BBC following precolonization with G. vaginalis. Number of cells is assessed following 24 hour colonization with a Lactobacillus mixture.

FIGS. 22A and 22B show the number of G. vaginalis CFU following colonization with the selected Lactobacillus strains alone or in mixes. (FIG. 22A) numbers of epithelial cell associated G. vaginalis CFUs following simultaneous infection with G. vaginalis and vaginal lactobacilli alone or in Mix 1 (1:1:1 ratio of Lg:Lc:Lj). (FIG. 22B) Numbers of epithelial cell associated G. vaginalis CFU following colonization with the indicated combination of Lg, Lc. Lj, or Mix 1 (1:1:1 ratio of Lg:Lc:Lj), Mix 5 (1:3:2 ratio of Lg:Lc:Lj), Mix 6 (2:3:1 ratio of Lg:Lc:Lj), and Mix 7. (Lc-=L. crispatus 223310, Lj=L. jensenii 2054210, and Lg=L. gasseri 29313).

FIGS. 23A and 23B shows activities of a 3-strain cocktail against signature BV pathogens. The lactobacillus mix maintained a reproducible colonization rate when applied to vaginal cells alone or when allowed to compete with equal numbers of G. vaginalis (Gv) and P. bivia (Pb), isolated from women with BV (FIG. 23A, left panels). At the same time the BBC bacteria prevented Gv and Pb colonization (FIG. 23A, right panel) and suppressed the proinflammatory activities of both BV pathogens assessed by IL-8 levels (FIG. 23B). Total Lactobacillus CFU counts (L. gasseri, +L. crispatus+L. jensenii) are shown here for the cumulative colonization rates.

FIG. 24 shows cytokines and chemokines indicated measured in vaginal and serum samples from gnotobiotic mice exposed to beneficial bacteria (L crispatus) and BV bacteria (P. bivia)

FIGS. 25A-25C show the stability of bacteria using preservation by vaporization (PBV). (FIG. 25A) Stability of PBV bacteria stored over a 2 year period at indicated temperatures. (FIG. 25B) Preservation of epithelial tissue colonization capacity of PBV stored over a 2 year period at indicated temperatures. (FIG. 25C) Vaginal epithelial colonization by individual and mixed PBV bacteria (Lc-=L. crispatus 223310, Lj=L. jensenii 2054210, and Lg=L. gasseri 29313) stored over 1 year at ambient RT (>25° C.) after PBV preservation and compared to bacterial stocks stored frozen. Bars are means and SEM from biological duplicates in four experiments.

DETAILED DESCRIPTION

The compositions and methods described herein are based, in part, on the discovery that a bacterial mixture comprising a limited number of viable Lactobacillus species is effective in treating and preventing vaginal dysbiosis, and promoting a healthy vaginal flora. It was discovered that the combination of L. crispatus, L. gasseri, and L. jensenii results in a synergistic effect that promotes the growth of the community within the bacterial mixture, as well as the capacity for the bacterial mixture to combat T. vaginalis and B. gardneri vaginal colonization. This effect was particularly prominent with L crispatus strain 223310, L. jensenii strain 2054210, and L gasseri strain 29313. The selected strains are derived from healthy reproductive age women, or healthy pregnant women who went on to give birth after at 38-40 weeks of gestation. In vivo assays established that the selected strains do not elicit a proinflammatory response. It was also found that the proportions of the members of the consortium or cocktail influence the efficacy of the formulation. Described herein are proportions of the Lactobacillus species within the bacterial mixture that are particularly effective when using this combination of Lactobacilli to treat vaginal bacterial infection and/or promote a healthy vaginal flora.

Various considerations useful for the practice of the compositions and methods disclosed herein are set out in the following.

Maintaining a Healthy Vaginal Microbiota Balance

While exact species and proportions can vary among healthy women, the healthy resident vaginal microbiome is dominated by Gram positive, non-spore-forming, lactic acid-producing bacteria of the Lactobacillus genus. In a healthy woman, Lactobacillus species represent upwards of 95% of the resident vaginal bacteria. Among other things, the production of lactic acid as a product of normal Lactobacillus metabolism functions to maintain an acidic pH in the vagina (generally pH 3.8-4.5), which provides an environment that discourages the growth of most vaginal pathogens. Species of Lactobacilli adapted to the vaginal environment have the ability to adhere to vaginal epithelia, to inhibit the adhesion and growth of pathogens and to deplete nutrients that otherwise permit the growth of pathogens. Such species also modulate the host's immune response, generally maintaining or promoting a non-proinflammatory status. A large body of epidemiologic evidence demonstrates that the resident vaginal bacteria are intimately involved in innate immunity in the female genital tract, with major consequences for women's and infants' health if disrupted.

Vaginal dysbiosis is a disruption of the balance of Lactobacillus-dominated resident vaginal bacteria of the healthy vagina, and involves or permits the establishment, growth or expansion of one or more species of non-Lactobacillus species of microbe. Vaginal dysbiosis can be initiated, for example, by iatrogenic interventions, sexual behavior or hormonal change, infections, systemic stress, malnutrition or illness. Vaginal dysbiosis can lead to vaginitis, bacterial translocation or bacterial vaginosis (BV), which is the most common morbid microbiological syndrome among women of childbearing age, characterized by a shift from a Lactobacillus-dominated bacteriome to more diverse polymicrobial states with abundant Prevotella, Atopobium, Gardnerella and other less characterized anaerobes. BV is associated with adverse pregnancy outcome, e.g. preterm birth, sexually transmitted infections and higher risk of HIV acquisition, cervicovaginal viral shedding and transmission. Antibiotic treatment is often ineffective to cure and prevent the frequent relapses of BV, and even capable of worsening reproductive outcome.

Compositions and methods are described herein for maintaining, establishing and/or restoring a healthy vaginal microbiota balance. The compositions and methods are based, in part, upon the identification of a consortium of three probiotic Lactobacillus species that act synergistically to affect a healthy vaginal microbiota balance. More specifically, strains of L. crispatus, L. jensenii and L. gasseri have been isolated from healthy pregnant human vaginal samples and, together, promote or maintain a healthy human vaginal microbiota balance. Indeed, as demonstrated in the Examples provided herein, the strains identified can not only discourage growth of pathogenic microbes common in bacterial vaginosis or in fungal vaginitis, but can actually treat such conditions. The strains identified grow better in combination than singly, both in vitro and in vivo, meaning that one or more of the species produces or modifies a metabolite that promotes the growth or viability of one or more of the others. In addition, it was also found that not just the presence of the identified strains, but the ratios in which they are introduced relative to each other are important for establishing and maintaining a healthy vaginal microbiota balance. These aspects and others are described further in the following.

Lactobacillus Species

By “Lactobacillus” is meant any bacteria from the genus Lactobacillus, including L. crispatus, L. jensenii, and L. gasseri, among others. Numerous other species are outlined by Wood et al. (Holzapfel and Wood, eds. (1995) The Genera of Lactic Acid Bacteria, Vol. 2., Springer, N.Y.). Lactobacilli are members of a larger group of lactic acid bacteria, all of which are Gram positive, non-spore-forming cocci, coccobacilli or rods. Lactobacilli have a DNA base composition with less than 50% G+C, do not express catalase and rely upon a fermentable carbohydrate for growth. They are members of the phylum Firmicutes, class Bacilli, order Lactobacillales and family Lactobacillaceae. Species of Lactobacilli can be identified phenotypically, as well as genetically, e.g., on the basis of 16S rRNA sequence (or more often in practice, the DNA encoding the 16S rRNA, generally referred to as 16S rDNA).

Lactobacillus species L. crispatus, L. jensenii and L. gasseri described herein were isolated from healthy pregnant women using a selective approach described herein below. It is noted that where one focus of the work described herein was to identify species that promote or maintain a healthy vaginal microbiota or healthy vaginal microbiota balance in pregnant women, e.g., to reduce risk of pre-term birth or other complications associated with vaginal dysbiosis during pregnancy, the methods and compositions described herein are equally applicable to non-pregnant women and girls.

By focusing on the healthy vaginal microbiome it is much more likely that identified species of microbes will be non-pathogenic, non-proinflammatory and well adapted to the healthy vaginal environment. Apart from being isolated from a healthy woman, e.g., a healthy pregnant or non-pregnant woman, characteristics of Lactobacillus species or strains appropriate for the compositions and methods described herein include, for example, stable colonization of human vaginal epithelium in a culture model as described herein in the Examples, and not provoking a local or systemic inflammatory or immune response as evidenced, for example, by assays using gnotobiotic mice and measuring proinflammatory cytokines such as IL-1β and TNF-α, or the downstream effector chemokine GRO/KC. Additional characteristics include, for example, maintenance of the balance of anti-inflammatory and proinflammatory mediators in vaginal epithelial cells colonized by the species or strain, and not altering the ability of the vaginal epithelium to mount innate responses to pathogenic determinants, e.g., as measured by the ability to respond to synthetic ligands for TLR2/6 (mimetic of bacterial lipoprotein) and TLR3 (mimetic for viral dsRNA).

Appendix A includes additional 16S rRNA gene sequences for the inactive or less active strains of L. crispatus, L. jensenii, and L. gasseri. Appendix A discloses SEQ ID NOS 49-51 and 7-30 in order as they appear.

Appendix B includes additional 16S rRNA gene sequences of L. crispatus, L. jensenii, and L. gasseri strains that were less optimal by one or more criteria but showed beneficial clinical phenotype. Appendix B discloses SEQ ID NOS 49-51 and 31-48 in order as they appear.

Appendix C includes phenotypic characteristics of L. crispatus, L. jensenii, and L. gasseri strains.

In one embodiment, the Lactobacillus crispatus strain is 223310 (BWH invention reference #23158; ATCC Deposit PTA-127090, deposited Jul. 9, 2021). The deposit was made at American Tissue Culture Collection (ATCC), having a mailing address of 10801 University Boulevard, Manassas, Va. 20110 USA. The 16S rDNA sequence of L. crispatus strain 223310 is as follows

L. crispatus strain 223310 ATCC PTA-127090 16S  rRNA gene sequence generated with 27f forward  primer follows (SEQ ID NO: 1): TGCAGTCGAGCGAGCGGAACTAACAGATTTACTTCGGTAATGACGTTAGG AAAGCGAGCGGCGGATGGGTGAGTAACACGTGGGGAACCTGCCCCATAGT CTGGGATACCACTTGGAAACAGGTGCTAATACCGGATAAGAAAGCAgATC GCATGATCAGCTTTTAAAAGGCGGCGTAAGCTGTCGCTATGGGATGGCCC CGCGGTGCATTAGCTAGTTGGTAAGGTAAAGGCTTACCAAGGCGATGATG CATAGCCgAgtTGAGAGACTGATCGGCCACATTGGGACTGAGACACGGCC CAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGCAAG TCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGC TCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACG GTAATCAACCAGAAAGTCACGGCTAACT L. crispatus strain 223310 ATCC PTA-127090 16S  rRNA gene sequence generated with 529R reverse  primer as follows (SEQ ID NO: 2): CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAG CTTTACGATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGAC TTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGG GCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGC ATCATCGCCTTGGTAAGCCTTTACCTTACCAACTAGCTAATGCACCGCGG GGCCATCCCATAGCGACAGCTTACGCCGCCTTTTAAAAGCTGATCATGCG ATCTGCTTTCTTATCCGGTATTAGCACCTGTTTCCAAGTGGTATCCCAGA CTATGGGGCAGGTTCCCCACGTGTTACTCACCCATCCGCCGCTCGCTTTC CTAACGTCATTACCGAAGTAAATCTGTTAGTTCCGCTCGCTCGACTTGCA TGTATTAGGCACGCCGCCAGCGTTC

Strains in addition to L. crispatus strain 223310, including L. crispatus ATCC 3820, a H₂O₂ producing strain of L. crispatus received from Dr. Sharon Hillier, and Brigham and Women's Hospital (BWH) L. crispatus strains 101211 and 24629 were investigated for activity in the assays described herein in the Examples, but found to be inactive or less active in one or more criteria examined than L. crispatus strain 223310. Appendix A includes additional 16S rRNA gene sequences for the inactive or less active strains are set out herein. Appendix B includes additional 16S rRNA gene sequences of strains that were less optimal by one or more criteria but showed beneficial clinical phenotype. Appendix C includes phenotypic characteristics of L. crispatus strain 223310.

In one embodiment, the Lactobacillus jensenii strain is 2054210 (BWH invention reference #23379; ATCC Deposit # PTA-127092, deposited Jul. 9, 2021). The deposit was made at American Tissue Culture Collection (ATCC), having a mailing address of 10801 University Boulevard, Manassas, Va. 20110 USA.

The L. jensenii strain 2054210 ATCC PTA-127092  16S rRNA gene sequence generated with 27F  forward primer is as follows (SEQ ID NO: 3): TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATA CAAGCTAGCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGT CTGGGATACCATTTGGAAACAGATGCTAATACCGGATAAAAGCTACTTTC GCATGAAAGAAGTTTAAAAGGCGGCGTAAGCTGTCGCTAAAGGATGGACC TGCGATGCATTAGCTAGTTGGTAAGGTAACGGCTTACCAAGGCGATGATG CATAGCCGAGTTGAGAGACTGATCGGCCACATTGGGACTGAGACACGGCC CAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGCAAG TCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGC TCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACG GTAATCAACCAGAAAGTCACGGCTAACTACG The L. jensenii strain 2054210 ATCC PTA-127092  16S rRNA gene sequence generated with 529R  reverse primer as follows (SEQ ID NO: 4): CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAG CTTTACGATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGAC TTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGG GCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGC ATCATCGCCTTGGTAAGCCGTTACCTTACCAACTAGCTAATGCATCGCAG GTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAAACTTCTTTCATGCG AAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTATCCCAGA CTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCA TGTATTAGGCACGCCGCCAGCGTTC

Strains in addition to L. jensenii strain 2054210, including L. jensenii ATCC 25258, L. jensenii 1153 and several others listed in were investigated for activity in the assays described herein in the Examples, 16S rRNA gene sequences strains are set out herein in Appendix A. 16S rRNA gene sequences of strains that were less optimal by one or more criteria but showed beneficial clinical phenotype are included in Appendix B. Phenotypic characteristics of L. jensenii strain 2054210 are included in Appendix C.

In one embodiment, the Lactobacillus gasseri strain is 29313 (BWH invention reference #23380; ATCC Deposit # PTA-127091, deposited 7/9/2021), also known as L. acidophilus 239-13. The deposit was made at American Tissue Culture Collection (ATCC), having a mailing address of 10801 University Boulevard, Manassas, Va. 20110 USA.

The L. gasseri strain 29313 ATCC PTA-127091 16S  rRNA gene sequence generated with 27F forward  primer as follows (SEQ ID NO: 5): TGCAGTCGAGCGAGCTTGCCTAGATGAATTTGGTGCTTGCACCAaATGAA ACTAGATACAAGCGAGCGGCGGACGGGTGAGTAACACGTGGGTAACCTGC CCAAGAGACTGGGATAACACCTGGAAACAGATGCTAATACCGGATAACAA CACTAGACGCATGTCTAGAGTTTAAAAGATGGTTCTGCTATCACTCTTGG ATGGACCTGCGGTGCATTAGCTAGTTGGTAAGGCAACGGCTTACCAAGGC AATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACATTGGGACTGAGA CACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGG ACaCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGGTTTCGGCTC GTAAAGCTCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGCCTTTA TTTGACGGTAATTACTTAGAAAGTCACGGCTAACTACGTGCC The L. gasseri strain 29313 ATCC PTA-127091 16S  rRNA gene sequence generated with 529R reverse  primer as follows (SEQ ID NO: 6): TATTACCGTCAATAAAGGCCAGTTACTACCTCTATCTTTCTTCACTACCA ACAGAGCTTTACGAGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCA TCAGACTTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGA GTTTGGGCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGG CTATGCATCATTGCCTTGGTAAGCCGTTGCCTTACCAACTAGCTAATGCA CCGCAGGTCCATCCAAGAGTGATAGCAGAACCATCTTTTAAACTCTAGAC ATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCCAGGTGTTATC CCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGCTCG CTTGTATCTAGTTTCATtTGGTGCAAGCACCAAATTCATCTAGGCAAGCT CGCTCGACTTGCATGTATTAGGCACGCCGCCAGCGTTCG

Strains in addition to L. gasseri strain 29313, including Brigham and Women's Hospital (BWH) L. gasseri strains 117427 and 217213 were investigated for activity in the assays described herein in the Examples, but failed to meet criteria based on clinical phenotype. 16S rRNA gene sequences for these strains are set out herein in Appendix A. 16S rRNA gene sequences of strains that were less optimal by one or more criteria but showed a promising clinical phenotype are included in Appendix B. Phenotypic characteristics of L. gasseri 29313 are included in Appendix C.

The above lactic acid bacteria include, for example but not limited to, viable bacteria, wet bacteria, dry viable bacteria (e.g., preparations including viable spray-dried cells, freeze-dried cells, vacuum-dried cells, drum-dried cells, vitrified etc.), and the like. Preparations of Lactobacillus species described herein can include, for example, suspensions of Lactobacillus bacteria, cultured cells of Lactobacillus bacteria (including bacterial cells, supernatant, and medium ingredients), and cultured media containing Lactobacillus bacteria (obtained by removing solid contents from the cultured cells of bacteria). While viable Lactobacillus bacteria are used in most applications considered herein, it is contemplated that in some embodiments, processed cells of Lactobacillus bacteria can include, for example, ground cells, crushed cells, liquefied cells (extracts etc.), concentrates, paste-like cells, dried preparations thereof, and the like.

Vaginal Pathogens

By maintaining a healthy vaginal pH and otherwise affecting the vaginal mucosal and epithelial environment, methods and compositions described herein can provide a vaginal environment that discourages or inhibits the establishment or growth of pathogenic organisms in the female reproductive tract. In this manner, the compositions and methods described herein can provide protection from or treatment for, any of a number of vaginal pathogens. Non-limiting examples of vaginal pathogens known or contemplated to be influenced in this manner include Chlamydia trachomatis, Candida albicans, Candida galbrata, Candida parapsilosis, Candida tropicalis, Candida kefir, Candida krusei, Candida pseudotropicalis, Candida lusitaniae, Candida rugosa, Trichomonas vaginalis, and Gardnerella vaginalis. Susceptibility to viral infection can also be affected by vaginal dysbiosis, including, but not limited to susceptibility to infection with HIV, HPV and Herpesviruses; it is contemplated that Lactobacillus species or strains as described herein can reduce the likelihood or provide a degree of protective effect against these and other viral infections of the female reproductive tract.

Antibiotics

It is contemplated that compositions and methods described herein can be administered in combination with, or in conjunction with, antibiotic treatments aimed at killing or halting the growth of vaginal pathogens. Antibiotic treatments are often indiscriminate in the species they kill, such that the pathogen is killed along with the majority of the probiotic or commensal microbes of the vagina or female reproductive tract. In one embodiment, then, an infection can be treated by administering an antibiotic, and a Lactobacillus preparation or cocktail as described herein can be administered following the antibiotic to promote the restoration of a healthy vaginal microbiota or healthy vaginal microbiota balance. In other embodiments, it is contemplated that antibiotic treatment can be administered at the same time as a Lactobacillus cocktail as described herein. It is recognized that where a broad spectrum antibiotic is administered, it is likely to kill at least a portion of the Lactobacilli administered; however, at sufficiently high doses of the Lactobacillus cocktail, a benefit of co-administration with an antibiotic is contemplated. Alternatively, where an anti-fungal, such as fluconazole is administered to treat, e.g., a Candida infection, the antifungal would not be expected to have a strong effect on the Lactobacilli in the cocktails described herein, and either or both of co-administration and post-antifungal administration of a Lactobacillus cocktail as described herein may be indicated.

Any antibiotic effective against a vaginal pathogen can be used according to such embodiments. However, non-limiting examples include metronidazole, and other antibiotics from the nitroimidazole class e.g. tinidazole and secnidazole, clindamycin, nystatin, azithromycin, erythromycin, ofloxacin, doxycycline, levofloxacin, amoxicillin, or fluconazole at doses non-inhibiting the Lactobacillus vaginal colonization or not bactericidal for the lactobacillus strains.

It is additionally contemplated that compositions and methods described herein can be administered in combination with, or in conjunction with, antiseptics aimed at killing or halting the growth of vaginal pathogens. Examples include but are not limited to essential oils from medicinal plants that have strong antiseptic activities such as thymol (a natural monoterpene phenol found in thyme effective against Gardnerella biofilms) and eugenol (phenylpropene extracted from clove oil) can be used according to such embodiments. Other antiseptics such as glycerol monolaurate which is compatible with Lactobacillus growth and octenidine hydrochloride/phenoxyethanol can also be used according to such embodiments

Modified Lactobacillus Species

It is contemplated that one or more of the Lactobacillus species comprising a cocktail as described herein can be modified, e.g., genetically modified to express a beneficial product or a marker or indicator not normally expressed by that species. The beneficial effect can be on the host, or even, for example, on one or more of the other Lactobacillus members of the cocktail. Methods for genetically modifying bacteria are known to those of ordinary skill in the art.

In one embodiment, a Lactobacillus species member of a cocktail as described herein can be modified to express one or more anti-microbial peptides (AMPs) or bacteriocins, e.g., an AMP or bacteriocin that targets microbial (bacterial, fungal or even viral) species other than Lactobacilli. AMPs have been identified in species ranging from bacteria, amphibians to mammals, including humans. AMPs form a first line of host defense against pathogenic infections and are a key component of the ancient innate immune system. Most antimicrobial peptides comprise 6-50 amino acid residues, and carry a net positive charge. While not wishing to be bound by theory, it is generally thought that such cationic peptides selectively interact with anionic bacterial membranes, although different mechanisms may be used by some AMPs. A large collection of AMPs and their activities are described, for example, in the Antimicrobial Peptide Database (APD)—see, e.g., Wang et al., Nucleic Acids Res. 32 (Database issue): D590-D592 (2004), and Collection of Anti-Microbial Peptides (CAMP_(R3); at www.camp3.bicnirrh.res.in).

Compositions for Establishing or Maintaining a Healthy Vaginal Flora.

One aspect of the technology described herein is a composition comprising a mixture of viable Lactobacillus bacteria consisting of L. crispatus, L. gasseri, and L. jensenii, for the treatment and/or prevention of vaginal dysbiosis. In one embodiment of the aspect described herein, the ratio of viable bacteria in the composition is important for its efficacy.

In one aspect of the invention disclosed herein, the composition comprises a mixture of viable bacteria consisting of L. crispatus strain 223310, L. jensenii strain 2054210, and L. gasseri strain 29313.

In one embodiment, L. crispatus strain 223310 comprises 50-73.3% of the bacterial mixture, L. jensenii strain 2054210 comprises 6.67-33.4% of the bacterial mixture, and L. gasseri strain 29313 comprises 16.7-33.4% of the bacterial mixture.

In one embodiment, the bacterial mixture is comprised of 66.7% L. crispatus, 16.7% L jensenii, and 16.7% L. gasseri.

In one embodiment, the bacterial mixture is comprised of 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri.

In another embodiment, the bacterial mixture is comprised of 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri.

In another embodiment, the bacterial mixture is comprised of 73.3% L. crispatus, 6.7% L. jensenii, and 20% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and L. gasseri in the bacterial mixture is comprised of 66.7% L. crispatus, 16.7% L. jensenii, and 16.7% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and Lactob L. gasser in the bacterial mixture is comprised of 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and L. gasseri in the bacterial mixture is comprised of 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri.

In another aspect of the invention disclosed herein, the composition comprises a mixture of viable bacteria wherein L. crispatus comprises 50-73.3% of the bacterial mixture, L. jensenii comprises 6.67-33.4% of the bacterial mixture, and L. gasseri comprises 16.7-33.4% of the bacterial mixture.

In one embodiment, the bacterial mixture is comprised of 66.7% L. crispatus, 16.7% L. jensenii, and 16.7% L. gasseri.

In one embodiment, the bacterial mixture is comprised of 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri.

In another embodiment, the bacterial mixture is comprised of 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri.

In another embodiment, the bacterial mixture is comprised of 73.3% L. crispatus, 6.7% L. jensenii, and 20% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and L. gasseri in the bacterial mixture is comprised of 66.7% L. crispatus, 16.7% L. jensenii, and 16.7% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and Lactob L. gasser in the bacterial mixture is comprised of 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri.

In one embodiment, the total of L. crispatus, L. jensenii, and L. gasseri in the bacterial mixture is comprised of 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri.

In one embodiment, the composition comprises L. crispatus strain 223310, L. jensenii strain 2054210, and L. gasseri strain 29313.

In some embodiments, the combination of Lactobacillus species in the composition results in a beneficial synergistic effect that assists Lactobacillus survival and competition against vaginal pathogens. For example, L. crispatus did not maintain viable colony forming units in the presence of A. vaginae, or suppress epithelial colonization by A. vaginae. When in combination with L. gasseri and L. jensenii, L. crispatus does maintain viable colony forming units in the presence of A. vaginae, and suppressed epithelial colonization by A. vaginae. Additionally, L. jensenii is thought to promote a more strong suppression of the protozoan parasite, T. vaginalis.

In some embodiments, the compositions described herein further comprise one or more agents that promote bacterial growth. Non-limiting examples of agents that promote bacterial growth include boric acid, a prebiotic, and low pH buffering agents as sodium bicarbonate and agents that can act as both acidifying and prebiotics, such as ascorbic acid (vitamin C).

Boric acid is used in vaginal douches to treat bacterial vaginosis due to its high alkalinity, which confers its antimicrobial property. Boric acid, in various forms, is additionally used as an antimicrobial for the treatment of acne, athlete's foot, and for certain ear infections.

Prebiotics promote the growth, survival, and activity of beneficial microorganisms, for example Bifdobacteria and Lactobacillus. Prebiotics have been shown to alter the compositions of microorganisms (microflora) in the gut microbiome, and are contemplated for assisting in the maintenance of a healthy vaginal flora, alone or in combination with Lactobacillus cocktail compositions described herein. In addition, prebiotics have been shown to increase calcium and magnesium absorption in the gut, increase bone density, enhance the immune system, reduce blood triglyceride levels, and control hormone levels. Prebiotics include any of a number of compositions that are generally not directly digestible by humans, but that are readily digestible by and promote the growth or establishment of probiotic microbes. Topical vaginal application of the prebiotic sucrose is an effective therapeutic in patients with symptomatic BV. Non-limiting examples of other prebiotics include but are not limited to inulin, fructooligosaccharides, galactooligosaccharides, hemicelluloses (e.g., arabinoxylan, xylan, xyloglucan, and glucomannan), chitin, lactulose, mannan oligosaccharides, oligofructose-enriched inulin, gums (e.g., guar gum, gum arabic and carregenaan), oligofructose, oligodextrose, tagatose, resistant maltodextrins (e.g., resistant starch), trans-galactooligosaccharide, pectins (e.g., xylogalactouronan, citrus pectin, apple pectin, and rhamnogalacturonan-I), dietary fibers (e.g., soy fiber, sugarbeet fiber, pea fiber, corn bran, and oat fiber) and xylooligosaccharides.

The vaginal pH ranges from 3.8 to 4.5 in a healthy subject. This acidic pH promotes the growth of beneficial bacterial (for example Lactobacillus) and prevents the overgrowth of vaginal pathogens that cause odor, irritation, and infection. Buffering agents are weak acids or bases that maintain the acidity at a chosen level and prevent a rapid change in acidity. A non-limiting example of a low pH buffering agents are lactic acid and sodium bicarbonate.

In one embodiment, the composition further comprises at least one excipient. Excipients are substances added to an active ingredient for the purpose of long-term stabilization, bulking up solid formulations that contain active ingredients (known as “bulking agents”), or to enhance or protect the therapeutic benefit of an active ingredient by facilitating drug absorption, reducing viscosity, or increasing solubility or reconstitution from a dry state. Non-limiting examples of protective excipients include a nonreducing monosaccharide, sugar alcohol, oligosaccharide, amino acid, polyvinylpyrrolodone, polyethylene glycol, Ficol, inulin, albumin, gelatin, whey proteins, and/or a polaxomer. In some embodiments, the composition further comprises at least one, at least two, at least three, at least four, or at least five or more protective excipients.

In one embodiment, the bacteria comprised by the composition are lyophilized, or freeze-dried in a manner that preserves bacterial viability. Methods of preserving viable bacteria by lyophilization can promote long-term preservation of the microorganism. One skilled in the art will be able to lyophilize bacteria using standard techniques. Briefly, microbes are cultured and suspended in lyophilizing buffer or medium. The microbes are rapidly frozen and then subjected to a primary and secondary drying phase to remove all readily available water and residual water, respectively. Storage at 4° C. or lower is recommended, with no moisture present. Standard bacterial lyophilizing techniques can be found in Perry, S.F., Cryopreservation and freeze-drying protocols. Volume 38, pg 21-30.

In some embodiments, the composition is formulated for vaginal delivery for treatment and/prevention of vaginal dysbiosis. Non-limiting examples of vaginal delivery methods include vaginal tablets, capsules, suppositories, creams, and douches. In one embodiment, the composition will be preserved by drying on film, for example preservation by vaporization (PBV).

PBV, as disclosed in U.S. Pat. No. 9,469,835, incorporated herein by reference, allows biological to be stable at higher temperatures for an extended period of time. Using PBV, the composition disclosed herein maintained its viability and capacity to colonize vaginal epithelium up to 2 year at room temperature (approximately 23° C.), and up to 9 months at 37° C. In one embodiment, the composition disclosed herein maintained its viability and capacity to colonize vaginal epithelium at least 2 weeks, at least 3 weeks, at least 1 month, at least 2 months, at least 3 month, at least 4 months, at least 5 month, at least 6 months, at least 7 month, at least 8 months, at least 9 month, at least 10 months, at least 11 month, at least 12 months, at least 13 month, at least 14 months, at least 15 month, at least 16 months, at least 17 month, at least 18 months, at least 19 month, at least 20 months, at least 21 month, at least 22 months, at least 23 month, at least 24 months or longer.

In one embodiment, the bacterial mixture preserved by PBV will comprise 50-73.3% L. crispatus, 6.67-33.4% L. jensenii, and 16.7-33.4% L. gasseri. In one embodiment, the bacterial mixture used preserved by PBV will comprise 66.7% L. crispatus, 16.7% L. jensenii, and 16.7% L. gasseri. In one embodiment, the bacterial mixture preserved by PBV will comprise 50% L. crispatus, 33.4% L. jensenii, and 16.7% L. gasseri. In one embodiment, the bacterial mixture preserved by PBV will comprise 50% L. crispatus, 16.7% L. jensenii, and 33.4% L. gasseri. In one embodiment, the bacterial mixture preserved by PBV will comprise 73.3% L. crispatus, 6.7% L. jensenii, and 20% L. gasseri.

In one embodiment, the composition can be formulated for controlled- or extended-release. Controlled-release pharmaceutical products have a common goal of improving drug therapy over that achieved by their non-controlled release counterparts. Ideally, the use of an optimally designed controlled-release preparation in medical treatment is characterized by a minimum of drug or active substance being employed to cure or control the condition in a minimum amount of time. Advantages of controlled-release formulations include: 1) extended activity of the drug or active substance; 2) reduced dosage frequency; 3) increased patient compliance; 4) usage of less total drug or active substance; 5) reduction in local or systemic side effects; 6) reduction in blood level fluctuations, where appropriate; 7) improvement in efficacy of treatment; 8) reduction of potentiation or loss of drug activity; and 9) improvement in speed of control of diseases or conditions. Kim, Cherng-ju, Controlled Release Dosage Form Design, 2 (Technomic Publishing, Lancaster, Pa.: 2000).

Most controlled-release formulations are designed to initially release an amount of drug or active ingredient that promptly produces the desired therapeutic effect, and gradually and continually release other amounts of drug or active ingredient to maintain this level of therapeutic or prophylactic effect over an extended period of time. In order to maintain this constant level, the drug or active ingredient must be released from the dosage form at a rate that will replace the amount of drug or avive ingredient being metabolized or otherwise lost from the body. Controlled-release of an active ingredient can be stimulated by various conditions including, but not limited to, pH, ionic strength, osmotic pressure, temperature, enzymes, water, and other physiological conditions or compounds.

A variety of known extended-release dosage forms, formulations, and devices can be adapted for use with viable bacterial compositions described herein. Examples include, but are not limited to, those described in U.S. Pat. Nos. 3,845,770; 3,916,899; 3,536,809; 3,598,123; 4,008,719; 5,674,533; 5,059,595; 5,591,767; 5,120,548; 5,073,543; 5,639,476; 5,354,556; 5,733,566; and 6,365,185 Bi; each of which is incorporated herein by reference. These dosage forms can be used to provide slow or controlled-release of one or more active ingredients using, for example, hydroxypropylmethyl cellulose, other polymer matrices, gels, permeable membranes, osmotic systems (such as OROS® (Alza Corporation, Mountain View, Calif. USA)), or a combination thereof to provide the desired release profile in varying proportions.

In another embodiment, delivery methods and compositions can include encapsulation technology, including, but not limited to a gel composition or gelator. See, e.g., US2011/0229565, US2013-0280334, and US2017/0100342, which describe self-assembling gel compositions that can solidify to encapsulate one or more agents. Each of these references is incorporated herein by reference. Gelators liquefy at a certain pH, releasing the one or more agents they encapsulated.

Methods for Identifying Microbial Strains that Promote Vaginal Health.

One aspect of the invention disclosed herein relates to a method of identifying bacterial strains that are beneficial in treating and/or preventing vaginal dysbiosis. The methods comprise isolating bacteria from the vagina of a healthy woman. Optionally, the healthy woman can be a healthy pregnant woman who will give birth after at 38-40 weeks of gestation (samples can be collected during pregnancy, and patient delivery outcomes followed to correlate those samples taken from patients who carried to full term). One skilled in the art of collecting and culturing bacteria will be able to isolate bacteria from the vagina using standard techniques for isolating the bacteria (for example vaginal swabs).

The methods further comprise isolating and verifying Lactobacillus species from the bacteria recovered from the vagina of a healthy woman via phenotypic and genetic analysis. One skilled in the art will be able to phenotypically identify Lactobacillus species using standard techniques. For example, one can phenotypically identify Lactobacillus species by using a combination of established microbiological techniques including: Vaginal pH, Nugent Score, Whiff Test, API 20E system (BioMerieux, Inc. Durham, N.C.), API 20 C AUX system (BioMerieux, Inc. Durham, N.C.), Rapid ANA II system (REMEL Inc., Norcross, Ga.), Microbial Identification System (Microbial ID Inc., Newark, Del.), Gas liquid chromatographic analysis of glucose fermentation products, Total anaerobe concentrations, Total aerobe concentrations, Enzymatic activity (Lipase, phospholipase A2 and phospholipase C, Hydrogen peroxide production. Genetic analysis can be performed using standard techniques, for example genome sequencing analysis. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) bioinformatics software can be used to functionally profile a microbial community based on markers, including, but not limited to the 16S ribosomal RNA (or 16S rDNA). This software can be used for genetic analysis of isolated strains.

The method further comprises verifying stable colonization of the isolated and verified Lactobacillus species in human vaginal epithelium, verifying that the isolated and verified Lactobacillus species do not elicit an immune response, verifying minimal mutual antagonism with the isolated and verified Lactobacillus, and verifying colonization of the isolated and verified Lactobacillus species in human vaginal epithelium in the presence of a vaginal pathogen.

These methods can be assessed using the in vivo model disclosed in Fichorova, R., et al. 2011. Mbio. 2(6), incorporated herein by reference. Briefly, healthy cervicovaginal epithelial cells are grown to confluence, and microorganisms are co-cultured with the confluent cervicovaginal epithelial cells. Colonization of the isolated and verified Lactobacillus species is assessed by using transmission electron microscopy (TEM) to observe constant epithelial-associated CFU without inducing cytotoxicity or apoptosis of the epithelial cells. Cytotoxicity and apoptosis of the cervicovaginal epithelial cells can be assessed using standard techniques known to one skilled in the art, for example an MTT assay (Catalog #M6494, Thermo Fisher Scientific, Waltham, Mass.).

To determine if the isolated and verified Lactobacillus species elicit an immune response, the confluent epithelium is collected, lysed, and the cellular supernatant is assessed for mediators of inflammation (e.g., IL-8, IL-γ, IL-β, and IL-α) using, e.g. western blot analysis or other immunoassay. See for e.g., Fichorova, 2004, Fichorova et al., 2011, Yamamoto et al., 2013).

To determine if there is minimal mutual antagonism, or competition between two or more isolated and verified Lactobacillus species, two or more species are co-cultured with cervicovaginal epithelial cells as described above. CFU for each species is assessed using TEM. Minimal mutual antagonism is achieved when at least 90% or more of a given bacterial species survives and proliferates when co-cultured with another bacterial species. In some embodiments, minimal mutual antagonism is evident when at least 95%, 96%, 97%, 98%, 99% or even 100% of a given species survives in the presence of another.

To determine if the isolated and verified Lactobacillus species can colonized on cervicovaginal epithelial cells in the presence of vaginal pathogens, the colonization assay described above is used, with the assay further comprising co-culturing the isolated and verified Lactobacillus species with a vaginal pathogen. Colonization of the Lactobacillus species is assessed as described above.

Dosages Forms and Administration

The dosages of compositions comprising a bacterial mixture that treat and or prevent vaginal dysbiosis can be determined by one of ordinary skill in the art depending on the clinical severity of the disorder (e.g., BV), the age and weight of the patient, and other pharmacokinetic factors generally understood in the art. The interrelationship of dosages for animals of various sizes and species and humans based on mg/m³ of surface area is described by E. J. Freireich et al., “Quantitative Comparison of Toxicity of Anticancer Agents in Mouse, Rat, Hamster, Dog, Monkey and Man,” Cancer Chemother. Rep. 50: 219-244 (1966). Adjustments in the dosage regimen can be made to optimize the therapeutic response. Doses can be divided and administered on a daily basis or the dose can be reduced proportionally depending on the therapeutic situation.

In some embodiments, the composition comprising a bacterial mixture for the treatment of vaginal dysbiosis are administered to a subject who has been diagnosed with, or at risk of developing, vaginal dysbiosis or bacterial infection. Microorganisms and/or spores can be separated and selected, using any one of a number of methods that are well known to those of ordinary skill in the art, for their bioactive properties to help ensure and improve the rate pathogen clearance. An effective amount of microorganisms and/or their spores is an amount sufficient to clear pathogens present in the vagina and restore a healthy vaginal flora. In accordance with these embodiments, an effective amount of microorganisms is from 100 thousand to 500 thousand, from 500 thousand to 1 million, from 1 million to 50 million, from 50 million to 100 million, from 100 million to 500 million, from 500 million to 1 billion, from 1 billion to 50 billion, from 50 billion to 100 billion, from 100 billion to 500 billion, from 500 billion to 600 billion CFU per dose, where the dose is administered, for example, daily, one or more times per week, or as often as about one to three times daily.

The dosage range depends upon the potency, and includes amounts large enough to produce the desired effect, e.g., a decrease in pathogens present in the vagina. The dosage should not be so large as to cause unacceptable adverse side effects. Generally, the dosage will vary with the type of agent (e.g., bacteria, an antimicrobial, boric acid, or a low pH buffering agent), and with the age, and condition of the patient. The dosage can be determined by one of skill in the art and can also be adjusted by the individual physician in the event of any complication. Typically, the dosage will range from 0.001 mg/kg body weight to 5 g/kg body weight. In some embodiments, the dosage range is from 0.001 mg/kg body weight to 1 g/kg body weight, from 0.001 mg/kg body weight to 0.5 g/kg body weight, from 0.001 mg/kg body weight to 0.1 g/kg body weight, from 0.001 mg/kg body weight to 50 mg/kg body weight, from 0.001 mg/kg body weight to 25 mg/kg body weight, from 0.001 mg/kg body weight to 10 mg/kg body weight, from 0.001 mg/kg body weight to 5 mg/kg body weight, from 0.001 mg/kg body weight to 1 mg/kg body weight, from 0.001 mg/kg body weight to 0.1 mg/kg body weight, from 0.001 mg/kg body weight to 0.005 mg/kg body weight. Alternatively, in some embodiments the dosage range is from 0.1 g/kg body weight to 5 g/kg body weight, from 0.5 g/kg body weight to 5 g/kg body weight, from 1 g/kg body weight to 5 g/kg body weight, from 1.5 g/kg body weight to 5 g/kg body weight, from 2 g/kg body weight to 5 g/kg body weight, from 2.5 g/kg body weight to 5 g/kg body weight, from 3 g/kg body weight to 5 g/kg body weight, from 3.5 g/kg body weight to 5 g/kg body weight, from 4 g/kg body weight to 5 g/kg body weight, from 4.5 g/kg body weight to 5 g/kg body weight, from 4.8 g/kg body weight to 5 g/kg body weight. In one embodiment, the dose range is from 5 μg/kg body weight to 30 μg/kg body weight. Alternatively, the dose range will be titrated to maintain serum levels between 5 μg/mL and 30 μg/mL.

The means by which the composition comprising the bacterial mixture described herein should be administered should be appropriate for the given composition. In one embodiment the composition will be administered orally. Microorganisms can be administered in a suspension in liquid form, in a slurry, in a capsule, or, for example, in dried form in a capsule. Methods for maintaining viability of microorganisms throughout the drying process are known to those of skill in the art. Microorganisms, including, but not limited to dried preparations, can also be formulated in enteric-coated or other forms such that when administered orally the microorganisms avoid killing in the harsh acidic conditions of the stomach and are only released to re-hydrate/reactivate in the relatively safer environment of the intestine. Microorganisms can also be administered in admixture with a food or beverage product, including, but not limited to a yogurt, kefir or other dairy product, or as dried microbes in, for example, a bar of cereal, granola, etc. Microorganisms useful in the methods and compositions described herein can also be prepared and/or administered in admixture with one or more prebiotic compositions that promote the maintenance, establishment and/or growth of the probiotic.

In another embodiment, the composition will be administered locally. In one embodiment, the composition is administered vaginally. Microorganisms can be formulated as a cream for topical administration. Microorganisms can be formulated as a vulvo-vestibular cream. Microorganisms can be administered in a suspension in liquid form for use in a douche, in a capsule or vaginal tablet, or, for example, in dried form in a capsule or vaginal tablet. Microorganisms can be dried on film, for example preservation by vaporization (PBV), for vaginal administration in which the microorganisms will re-hydrate/reactivate in the vaginal environment. In one embodiment, the composition is administered rectally.

Therapeutic compositions containing the composition comprising a bacterial mixture for the treatment of vaginal dysbiosis can be conventionally administered in a unit dose. The term “unit dose” when used in reference to a therapeutic composition refers to physically discrete units suitable as unitary dosage for the subject, each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect in association with the required physiologically acceptable diluent, i.e., carrier, or vehicle.

A therapeutically effective amount is an amount of composition comprising a bacterial mixture for the treatment of vaginal dysbiosis sufficient to produce a statistically significant, measurable change in e.g., reversal of damage, etc. (see “Efficacy Measurement” below). Such effective amounts can be gauged in clinical trials as well as animal studies for a given reduction agent.

Efficacy Measurement

The efficacy of a given treatment or prevention of vaginal dysbiosis can be determined by the skilled clinician. However, a treatment is considered “effective treatment,” as the term is used herein, if any one or all of the signs or symptoms of, as but one example, vaginal discharge and itching, or other clinically accepted symptoms or markers of disease are improved or ameliorated, e.g., by at least 10% following treatment with a composition comprising a bacterial mixture that treats or prevents vaginal dysbiosis described herein. Efficacy can also be measured by failure of an individual to worsen as assessed by need for medical interventions (e.g., progression of infection is halted or at least slowed). Methods of measuring these indicators are known to those of skill in the art and/or described herein. Example methods include whiff test, wet mount sample to assess the presence of bacteria, and a vaginal pH test. Treatment includes any treatment of a disease in an individual or an animal (some non-limiting examples include a human, or a mammal) and includes: (1) inhibiting the infection, e.g., arresting, or slowing symptoms of the infection, for example vaginal itching and burning; or (2) relieving the infection, e.g., causing regression of symptoms, reducing the symptoms by at least 10%; and (3) restoring healthy vaginal flora, thus preventing future vaginal dysbiosis.

An effective amount for the treatment of vaginal bacterial infection means that amount which, when administered to a mammal in need thereof, is sufficient to result in effective treatment as that term is defined herein, for that disease. Efficacy of the composition can be determined by a physician by assessing physical indicators of vaginal dysbiosis or infection, such as e.g., vaginal discharge and vaginal itching and burning.

The term “effective amount” as used herein refers to the amount of a probiotic or agent that reduces reactive oxygen species described herein needed to alleviate at least one or more symptom of a vaginal infection or dysbiosis, and relates to a sufficient amount of pharmacological composition to provide the desired effect. The term “therapeutically effective amount” therefore refers to an amount of a composition that is sufficient to provide a particular effect when administered to a typical subject. An effective amount as used herein, in various contexts, would also include an amount sufficient to delay the development of a symptom of the disorder, alter the course of a symptom (for example but not limited to, slowing the progression of a symptom of the disorder), or reverse a symptom of the disorder. Thus, it is not generally practicable to specify an exact “effective amount.” However, for any given case, an appropriate “effective amount” can be determined by one of ordinary skill in the art using only routine experimentation. The term “effective amount” is used interchangeably with the term “therapeutically effective amount” and refers to the amount of at least one agent, e.g., microbe or microbe-containing formulation that treats vaginal dysbiosis or infection, at dosages and for periods of time necessary to achieve the desired therapeutic result, for example, to reduce or stop at least one symptom of such vaginal dysbiosis or infection, in the subject.

Effective amounts, toxicity, and therapeutic efficacy of drug agents, e.g., for formulations or treatments using antibiotics in addition to microbes, can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD₅₀ (the dose lethal to 50% of the population) and the ED₅₀ (the dose therapeutically effective in 50% of the population). The dosage can vary depending upon the dosage form employed and the route of administration utilized. The dose ratio between toxic and therapeutic effects is the therapeutic index and can be expressed as the ratio LD₅₀/ED₅₀. Compositions and methods that exhibit large therapeutic indices are preferred. A therapeutically effective dose can be estimated initially from in vivo assays. Also, a dose can be formulated in animal models to achieve a circulating plasma concentration range that includes the IC₅₀ (i.e., the concentration of the active ingredient, which achieves a half-maximal inhibition of symptoms). Levels in plasma can be measured, for example, by high performance liquid chromatography or other appropriate technique. It is contemplated that the relevant level for an agent that reduced reactive oxygen species may also be the level achieved in the lumen of the gut, as opposed to a circulating level. The effects of any particular dosage can be monitored by a suitable bioassay. The dosage can be determined by a physician and adjusted, as necessary, to suit observed effects of the treatment.

Combination Therapies

In one embodiment, the method for treating vaginal dysbiosis described herein further comprises administering standard of care antibiotics for vaginal dysbiosis. Current standard of care antibiotics includes, but are not limited to administering subject who has been diagnosed with a vaginal bacterial infection tinidazole and secnidazole, clindamycin, nystatin, azithromycin, erythromycin, ofloxacin, doxycycline, levofloxacin, or amoxicillin, or an antifungal, fluconazole. Metronidazole is administered orally as a pill, or topically as a gel, clindamycin is administered topically as a cream, and tinidazole is administered orally as a pill. The use combination therapies should be assessed to determine that the standard of care treatment does not interfere or kill the bacterial mixture. Standard antibiotic sensitivity testing, for example a disc test, should be used to assess if the composition and a standard of care therapeutic should be combined. If the antibiotics interfere with the composition, it is contemplated that increasing the amount of composition administered would overcome this interference.

The composition for treatment of vaginal bacterial infection and antibiotics for the same treatment can be combined in the same formulation. Alternatively, the composition and antibiotics can be separate but administered at substantially the same time. The composition and antibiotic can also be administered consecutively, for example the administration of the antibiotic can occur one day after administration of the composition.

In another embodiment, the bacterial mixture further comprises an antiparasitic compounds with activities against Trichomonas vaginalis (Adams et al., 2013, Dornbush et al., 2010, Shokar et al., 2012).

It should be understood that antibiotics or other agents that are contraindicated during pregnancy should not be administered to a subject who is pregnant.

Unless otherwise defined herein, scientific and technical terms used in connection with the present application shall have the meanings that are commonly understood by those of ordinary skill in the art. Further, unless otherwise required by context, singular terms shall include pluralities and plural terms shall include the singular.

It should be understood that this invention is not limited to the particular methodology, protocols, and reagents, etc., described herein and as such may vary. The terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention, which is defined solely by the claims.

All patents, patent applications, and publications identified are expressly incorporated herein by reference for the purpose of describing and disclosing, for example, the methodologies described in such publications that might be used in connection with the present invention. These publications are provided solely for their disclosure prior to the filing date of the present application. Nothing in this regard should be construed as an admission that the inventors are not entitled to antedate such disclosure by virtue of prior invention or for any other reason. All statements as to the date or representation as to the contents of these documents is based on the information available to the applicants and does not constitute any admission as to the correctness of the dates or contents of these documents.

EXAMPLES

Why Intervention to Correct Vaginal Bacteriome is Needed.

The state of bacteriome disturbance (vaginal dysbiosis) can lead to vaginitis, bacterial translocation or bacterial vaginosis (BV), which is the most common morbid microbiological syndrome among women of childbearing age, characterized by a shift from a Lactobacillus-dominated bacteriome to more diverse polymicrobial states with abundant Prevotella, Atopobium, Gardnerella and other less characterized anaerobes¹. Vaginal dysbiosis comprises conditions where the balance between the resident vaginal bacteria dominating the healthy vagina is disturbed by iatrogenic interventions, sexual behavior or hormonal change, infections, systemic stress, malnutrition or illness. Antibiotic treatment vaginal dysbiosis is ineffective, and thus alternative treatments are needed.

The Role of Maternal Microbes in Neonatal Inflammation and Morbidity

Especially worrisome is the association between BV and preterm birth. Preterm birth occurs in ˜10% of all pregnancies (>13% among African Americans), with devastating consequences for newborns, families, and societies⁵. 15 million children are born prematurely every year, and even if all countries with very high development index achieved the best standard of care recorded to date, the world would still experience a reduction of only <5%⁶. In the United States alone, the cost of preterm birth is over $50,000 per infant. While more preterm babies survive due to improved clinical care, the prospects for life quality remain poor for many, due to our lack of therapeutic targeting of fundamental preventable mechanisms of neonatal mortality and morbidity. The perinatal inflammation associated with vaginitis and ascendance of vaginal pathogens to the placenta^(7,8) is linked in turn to intrauterine growth retardation 9,10 and brain damage in the preterm born, as well as learning disabilities, attention deficit/hyperactivity, and developmental delay in newborns who survive¹¹⁻¹⁹. Among the life-long disabilities are cerebral palsy^(20,21), asthma²², schizophrenia²³⁻²⁴, autism²³, epilepsy^(20,25), and low IQ²⁶. Research has shown that preterm infants with levels of inflammatory proteins in the top quartile for their age-matched peers population, especially when having 5 or more inflammation proteins increased, have much higher risk of developing ventriculomegaly, cerebral palsy, diparesis, hemiparesis, metal development delay (MDI<50), microcephaly and attention problems^(8,11,12,14,27-50) (FIG. 1). As many as 16 or 25 measured mediators of inflammation are increased in the systemic circulation of infants born to mothers with cervicitis and vaginitis⁸ (FIG. 2). Maternal microbes ascend in the placenta at high rate and in preterm infants are associated with higher risk of inflammation. In particular BV bacteria ascendance and colonization of the placenta is associated with increased levels of⁹ of the inflammatory markers associated with developmental delays and severe neurologic disorders⁴⁹ (FIGS. 3 and 4)

Conclusions: Medicinal vaginal probiotics must target cervicovaginal inflammation and ascendance of BV bacteria to the placenta. Ascendance of lactobacilli to the placenta is beneficial.

Choice of Lactobacillus Species

Various Lactobacillus species are not equal in their impact on the vaginal immunobiome. Most abundant in the vaginal environment are L. inners, L. cristatus, L. gasseri and L. jensenii. Details of L. gasseri isolation and genomic analysis are known in the art, see e.g., Fashemi B., et al. (2013) Microbial Ecology in Health and Disease; Fichorova R N, et al. (2011) mBio; Fichorova R N, Buck O R, Yamamoto H S, et al. (2013) Sex Transm Infect.; Yamamoto H S, Xu Q, and Fichorova R N. (2013) BMC Microbiology, which are incorporated herein by reference in their entireties. Genomic studies have associated them with microbiome community state types that are typically associated with non-BV Nugent scores (the classic microbiological measure of vaginal health¹ (FIG. 5). However, L. inners has turned out to be associated with increased levels of inflammatory cytokines and other signs of unwanted immune activation indicative of inflammatory state in women in contrast to the other abundant Lactobacillus species that are associated with lower cervicovaginal levels of inflammation⁵¹ (FIGS. 6, 7A-7B, and 8A-8E). Comparing a NextGen derived community state type dominated by L. crispatus (CT1) to that dominated by L. iners (CT2) and to that of BV-dominate bacteria e.g. A. vaginae and G. vaginalis (CT3) or A. vaginae, G. vaginalis and P. bivia (CT4) in African women clearly showed that the L. crispatus is superior to L. iners since CT2 was associated with a tendency of higher levels of inflammatory cytokines compared to CT1, and similar to CT3 and CT4 (FIGS. 7A, 7B, and 8A-8E). The causative nature of these relationships was proven in our in vitro model⁵¹. Work described herein and other studies⁵²⁻⁵⁷ have provided clinical validation of our well-characterized in-vitro model (FIGS. 9A-9H) used in this invention for the assessment of our medical probiotic cocktail. Higher levels of inflammation and inflammatory mediators have been linked to lower anti-microbial activity of the cervicovaginal secretions of women with BV⁵³.

Conclusions: The population of the vaginal environment with Lactobacillus bacteria that maintain a low inflammatory state is highly desirable. Among the most abundant and most affected by BV vaginotropic, Lactobacilli, L. crispatus, L. gasseri and L. jensenii are better candidates for medicinal vaginal probiotic products compared to L. iners. The in-vitro model described herein is well suited for testing candidate products as it is well established and predicts clinical findings.

Why a Bacterial Cocktail?

Because healthy women appear to have a microbiome dominated by either one of different Lactobacillus species, having a mix of the most common non-inflammatory species provides a sound clinical approach to a medicinal probiotic product targeted to diverse human populations.

Based on results described herein and published evidence described the following combination of L. crispatus, L. jensenii and L. gasseri was selected from a well-characterized pool of vaginal isolates generated at Brigham and Women's Hospital under IRB approved protocols with no tracking back to the human research subjects.

This model provided further rationale choosing a cocktail of bacterial species rather than a single species based medicinal product (FIGS. 10-12). When seeded alone in the absence of epithelial cells, the lactobacilli grew comparably in the presence or absence of BV-signature bacterium A. vaginae and even suppressed the growth of A. vaginae on agar (FIG. 10). However, when allowed to colonize epithelial cells, L. gasseri but not L. crispatus maintained viable colony forming units in the presence of A. vaginae and L. gasseri but not L. crispatus suppressed the epithelial colonization by A. vaginae (FIG. 11). These data indicated that in a therapeutic mix L. gasseri may assist L. crispatus in surviving in a BV environment. Furthermore, when tested individually, Lactobacillus jensenii was shown to be most resistant to the suppressive effects of T. vaginalis, a protozoan parasite that is the most common cause if vaginitis and frequent companion of BV (FIG. 12). These data supported our novel concept that a mix of the three species would be assisting Lactobacillus survival and competition against vaginal pathogens including BV bacteria and TV.

An important finding in the model is that no all Lactobacillus strains within a species are equal in their ability to maintain a homeostatic environment (FIG. 13A-13C). The strains differed by their immune properties measured by vaginal and cervical cytokines and chemokines (FIGS. 13A-13C). They could be ranked by levels of proinflammatory mediators included in current vaginal product safety algorithms due to their relevance to risk of viral infections, e.g. HIV and reproductive outcomes. Lactobacillus strains also differed by their ability to suppress colonization by the major BV biofilm forming organisms G. vaginalis (FIG. 13D). These findings confirmed the importance of choosing the right strains for the vaginal medicinal product.

Base on the findings reported herein, criteria for choosing the right bacterial strains for medicinal cocktail was established. The bacterial strain must meet the following criteria to be considered useful in treating BV: (1) was isolated from a healthy reproductive age woman or a pregnant woman with term delivery, (2) displays phenotypic and genetic proof of Lactobacillus species, (3) is distinct from commercially available strains, (4) has homeostatic immune properties, (5) can stably colonize the human vaginal epithelium, (6) displays competitive vaginal colonization in the presence of vaginal pathogens, and optionally (7) has in-vitro antimicrobial properties.

Medicinal Probiotic Cocktail

The cocktail is comprised of unique strains selected and combined in a specific manner through a unique combination of methods. The strains represent Lactobacillus crispatus, Lactobacillus jensenii, and Lactobacillus gasseri, which are dominant species in the vaginal microbiota of healthy women and associated with a healthy non-inflammatory vaginal microenvironment.

The bacterial isolates and the originating vaginal environment were phenotyped by a combination of established microbiological techniques including: Vaginal pH, Nugent Score, Whiff Test, API 20E system (BioMerieux, Inc. Durham, N.C.), API 20 C AUX system (BioMerieux, Inc. Durham, N.C.), Rapid A NA II system (REMEL Inc., Norcross, Ga.), Microbial Identification System (Microbial ID Inc., Newark, Del.), Gas liquid chromatographic analysis of glucose fermentation products, Total anaerobe concentrations, Total aerobe concentrations, Enzymatic activity (Lipase), phospholipase A2 and phospholipase C, Hydrogen peroxide production.

The species of strains identified was first confirmed by 16S-rRNA DNA sequencing on a selection of 43 bacterial isolates coming from a low risk healthy clinical environment. In addition, DNA deep sequencing library preparation of the three genomes and de novo genome assembly and Prokka annotation were completed. The molecular analysis confirmed species identity and identified unique features (FIGS. 14A-14C). Genome alignment of the three selected BBC strains and known genomes and BLASTN search identified that the three sequenced genomes are quite divergent from each other, sharing less than about 80% nucleotide sequence identity (FIG. 15). This is a highly desirable feature in that it supports the non-overlapping functional characteristic and functional genomics features as a basis of the strain synergisms. It is also desirable in there are many sites for strain/species-specific primers to allow PCR detection of the three strains in complex mixes in vivo, in animal safety and efficacy models and clinical trials. The functional properties of the chosen strains have been characterizes in a physiologic well-established in vitro model of the normal vaginal epithelium (FIGS. 13B-D, 16-22) and have obtained data from a gnotobiotic mouse model (FIG. 23). Endpoints of these observations were abilities of the strains to colonize the vaginal epithelial cells and to maintain a homeostatic immune environment. All three strains demonstrated stable and reproducible colonization by epithelial cells of the human female genital tract (FIG. 15A) without causing any epithelial damage (FIG. 15B). Gnotobiotic mouse model initially showed that no proinflammatory vaginal mucosal and systemic blood responses, measured by the major primary proinflammatory cytokines IL-1β and TNFα and the downstream effector chemokine GRO/KC, were induced by the selected strains applied vaginally by comparison of mock vaginal treatment, and vaginal inoculation of BV bacteria represented by the BV-signature bacterium P. bivia (FIG. 24). Findings in the in-vitro model indicated that none of the Lactobacillus isolates that were selected for the cocktail induce inflammation (FIG. 13B) and at the same time did not interfere significantly with the ability of the epithelial cells to respond to toll-like receptors stimulation by pathogen-associated patterns tested by classic tools e.g. synthetic ligands for TLR2/6 (mimic of bacterial lipoprotein) and TLR 3 (mimic of viral dsRNA) (FIG. 13B) Using novel methodology a formula that allows selection of the proportion of the three bacterial strains in a bacterial mix that allows a mutual support for growth and resistance to BV or activity against BV pathogens was established (FIGS. 17-23). The formula also allowed resistance to the microbiome perturbance caused by Trichomonas vaginalis (FIG. 18). The formula involves selection based on favorable growth (FIG. 17A-B) coupled with know-how to differentiate bacterial strains in a mix, and based on survival and steady colonization when seeded in a mix with BV pathogens (FIGS. 19A-19C) or following epithelial colonization by G. vaginalis, the microbe implicated in antibiotic-resistant BV biofilm formation¹ (FIG. 21). It was determined that the proportion of the bacteria in the cocktail matters for their survival in the epithelial cell context and have determined a few formulas of mixing the three selected BWH strains that yield an optimal proportion of colonization patterns (FIGS. 17A-17C). A synergistic colonization patter was observed resulting in a significantly higher Lactobacillus colonization rate achieved by the optimized 3-strain formulas as compared to the strains alone (FIG. 17B) and this phenomenon was confirmed in a bioengineered human tissue mimicking the lower female human genital tract (FIG. 20) The same synergetic effect was observed when the bacterial mixes were applied to the vaginal epithelial cells in the presence of BV pathogens (FIGS. 19A-19C). We have determined that epithelial colonization by G. vaginalis is suppressed when G. vaginalis was introduced to the epithelial cells in a mix with our Lactobacillus strains (FIG. 22A). G. vaginalis was also suppressed by our selected cocktail mixes even when lactobacilli were added after the epithelial cells were precolonized with G. vaginalis indicating a potential for not only preventive but also therapeutic effects of the cocktail (FIG. 22B). An optimal 3-strain mix not only suppressed colonization by signature BV bacteria G. vaginalis and P. bivia (FIG. 22C) but also simultaneously mitigated associated inflammatory responses (FIG. 23).

The more favorable functional characteristic of the bacterial cocktail include: (1) comprises of isolates from healthy women at low risk of preterm delivery and prior to term delivery; (2) each strains demonstrates phenotypic and genetic proof of Lactobacillus species; (3) each strains is distinct from commercially available strains based on sequence analysis of data available in the public domain based on Prokka annotation; (4) in optimized formulas the cocktail of the three strains colonizes the vaginal epithelial cells in a reproducible fashion and outcompetes colonization by BV associated bacteria; (5) our initial results show homeostatic lack of local and systemic inflammatory activation in a gnotobiotic mouse model by comparison to mock treatment and colonization with BV bacteria (P. bivia); (6) vaginal epithelial cells colonized by these strains maintain the homeostatic balance of anti-inflammatory and proinflammatory mediators; and (7) in formulas the strains mitigated perturbances by BV pathogens and Trichomonas vaginalis but did not alter the ability of the vaginal epithelium to mount innate immune responses to pathogenic determinants.

Choice of Vaginal Delivery System

There are many potential types of formulations and delivery methods that can be used for the disclosed medicinal bacterial mix. These include vaginal tablets, capsules, suppository, creams, films and douches. In addition, preservation by evaporation (PBV) allows biologicals to be stable at higher temperatures for a prolonged period of time. It was demonstrated that PBV-preserved Lactobacilli can colonize the vaginal epithelium in a reproducible fashion and maintain this ability after long-term storage at RT and higher temperatures. A lack of toxicity was confirmed and proinflammatory activity of several placebo films and bacteria-loaded films and stability of the PBV bacteria maintained at RT for up to 2 years and 37° C. for up to 9 months (FIGS. 25A-25C).

All publications cited herein expressly incorporated herein by reference in their entireties.

References for Example 1

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Sequence Listing (SEQ ID NO: 1): TGCAGTCGAGCGAGCGGAACTAACAGATTTACTTCGGTAATGACGTTAGG AAAGCGAGCGGCGGATGGGTGAGTAACACGTGGGGAACCTGCCCCATAGT CTGGGATACCACTTGGAAACAGGTGCTAATACCGGATAAGAAAGCAgATC GCATGATCAGCTTTTAAAAGGCGGCGTAAGCTGTCGCTATGGGATGGCCC CGCGGTGCATTAGCTAGTTGGTAAGGTAAAGGCTTACCAAGGCGATGATG CATAGCCgAgtTGAGAGACTGATCGGCCACATTGGGACTGAGACACGGCC CAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGCAAG TCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGC TCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACG GTAATCAACCAGAAAGTCACGGCTAACT (SEQ ID NO: 2): CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAG CTTTACGATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGAC TTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGG GCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGC ATCATCGCCTTGGTAAGCCTTTACCTTACCAACTAGCTAATGCACCGCGG GGCCATCCCATAGCGACAGCTTACGCCGCCTTTTAAAAGCTGATCATGCG ATCTGCTTTCTTATCCGGTATTAGCACCTGTTTCCAAGTGGTATCCCAGA CTATGGGGCAGGTTCCCCACGTGTTACTCACCCATCCGCCGCTCGCTTTC CTAACGTCATTACCGAAGTAAATCTGTTAGTTCCGCTCGCTCGACTTGCA TGTATTAGGCACGCCGCCAGCGTTC (SEQ ID NO: 3): TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATA CAAGCTAGCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGT CTGGGATACCATTTGGAAACAGATGCTAATACCGGATAAAAGCTACTTTC GCATGAAAGAAGTTTAAAAGGCGGCGTAAGCTGTCGCTAAAGGATGGACC TGCGATGCATTAGCTAGTTGGTAAGGTAACGGCTTACCAAGGCGATGATG CATAGCCGAGTTGAGAGACTGATCGGCCACATTGGGACTGAGACACGGCC CAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGCAAG TCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGC TCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACG GTAATCAACCAGAAAGTCACGGCTAACTACG (SEQ ID NO: 4): CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAG CTTTACGATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGAC TTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGG GCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGC ATCATCGCCTTGGTAAGCCGTTACCTTACCAACTAGCTAATGCATCGCAG GTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAAACTTCTTTCATGCG AAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTATCCCAGA CTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCA TGTATTAGGCACGCCGCCAGCGTTC (SEQ ID NO: 5): TGCAGTCGAGCGAGCTTGCCTAGATGAATTTGGTGCTTGCACCAaATGAA ACTAGATACAAGCGAGCGGCGGACGGGTGAGTAACACGTGGGTAACCTGC CCAAGAGACTGGGATAACACCTGGAAACAGATGCTAATACCGGATAACAA CACTAGACGCATGTCTAGAGTTTAAAAGATGGTTCTGCTATCACTCTTGG ATGGACCTGCGGTGCATTAGCTAGTTGGTAAGGCAACGGCTTACCAAGGC AATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACATTGGGACTGAGA CACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGG ACaCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGGTTTCGGCTC GTAAAGCTCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGCCTTTA TTTGACGGTAATTACTTAGAAAGTCACGGCTAACTACGTGCC (SEQ ID NO: 6): TATTACCGTCAATAAAGGCCAGTTACTACCTCTATCTTTCTTCACTACCA ACAGAGCTTTACGAGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCA TCAGACTTGCGTCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGA GTTTGGGCCGTGTCTCAGTCCCAATGTGGCCGATCAGTCTCTCAACTCGG CTATGCATCATTGCCTTGGTAAGCCGTTGCCTTACCAACTAGCTAATGCA CCGCAGGTCCATCCAAGAGTGATAGCAGAACCATCTTTTAAACTCTAGAC ATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCCAGGTGTTATC CCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGCTCG CTTGTATCTAGTTTCATtTGGTGCAAGCACCAAATTCATCTAGGCAAGCT CGCTCGACTTGCATGTATTAGGCACGCCGCCAGCGTTCG

APPENDIX A 16S rRNA gene sequences of strains that failed the selection algorithm Primer sequences 1) 27F: AGA GTT TGA TCM TGG CTC AG (SEQ ID NO: 49) 2) 1492R: CGG TTA CCT TGT TAC GAC TT (SEQ ID NO: 50) 3) 529R: CGC GGC TGC TGG CAC (SEQ ID NO: 51) L. jensenii BWH #24624 27F TGCAGTCGAGCGAGCTTGCCTATAGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGAAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCC (SEQ ID NO: 7) 529R CGTCaATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGA TCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTTCGTCCATTGTGGA AGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTGG CCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTACC AACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAAA CTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTATC CCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTAT CTATGTCCATTCCGAAGAATTTCTATAGGCAAGCTCGCTCGACTTGCATGTATTAGG CACGCCGCCAGCGTTC (SEQ ID NO: 8) L. jensenii BWH #564113 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTAC (SEQ ID NO: 9) 529R CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACG ATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTG GAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGT GGCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTA CCAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTA AACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTA TCCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTA GGCACGCCGCCAGCGTTC (SEQ ID NO: 10) L. jensenii BWH #1768213 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCA (SEQ ID NO: 11) 529R CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACG ATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTG GAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGT GGCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTA CCAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTA AACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTA TCCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTA GGCACGCCGCCAGCGTT (SEQ ID NO: 12) L. jensenii BWH #1949112 27F CGAgCTTGcCTATAtaAtTTCTTCtGAATGGACaTaaTaCAAgCTAGCGGCGGATGGGTGA GTAACGCGTGaGTAACCTGcCCTTAAGTcgGGgATACCATTTGGAAACagATGCTAATA CCgGATAAAAGCTACTTTCcCATGAAAGAAgTTTAAAAGGCGGtgtAAgCTGtCgCTAAa gGATGGACCTGCGATGCATTAGCTAgtTGGTAAGGTAACGGCTTAcCaAGGcgATGATG CaTAcCCGAgTTGA (SEQ ID NO: 13) 529R CTTTACgAtCCgAAagccTTCTTCACTCACGCGGCGTgGCTCCATCagacttgcgcCCATTGTG gAAGAtTCCCTACTGCTGCCTCCCGTAGGAGTtTGGgCCGTGTCTCAgTCCCAATGTGG CCGATCAGTCTCTCAaATCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTACCA ACTAGCTAATGCATCGcAGGTCCATCCtatAGCGAcAGcTtAcgCCGtCTTTtAAACTTCTT TCATGcGaatgTAGeTTTTATgCgGTATTAGCATCTGTTTCCAAATGGtATCCCAGACTTA aGGGcAGGTTAcCtacGCGTTACTCACCCaTCCGCCGCT (SEQ ID NO: 14) L. jensenii BWH #22448 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTAC (SEQ ID NO: 15) 529R CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACG ATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTG GAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGT GGCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTA CCAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTA AACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTA TCCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTA GGCACGCCGCCAGCGTTC (SEQ ID NO: 16) L. jensenii BWH #22410 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCAG (SEQ ID NO: 17) 529R CGTCaATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGA TCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTGG AAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTG GCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTAC CAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAA ACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTAT CCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTA TCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTAG GCACGCCGCCAGCGT (SEQ ID NO: 18) L. jensenii ATCC#25258 27F GCAGTCGAGCGAGCTTGCCTATAGAAGTTCTTCGGAATGGAAATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGAAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCAGCAGCCGCGGTAATACGTAGG TGGCAAGCGTTGTCCGGATTTATTGGGCGTAAAGCGAGCGCAGGCGGATTGATAAG TCTGATGTGAAAGCCTTCGGCTCAACCGAAGAACTGCATCAGAAACTGTCAATCTTG AGTGCAGAAGAGGAGAGTGGAACTCCATGTGTAGCGGTGGAATGCGTAGATATATG GAAGAACACCAGTGGCGAAGGCGGCTCTCTGGTCTGTAACTGACGCTGAGGCTCGA AAGCATGGGTAGCGAACAGGATTAGATACCCTGGTAGTCCATGCCGTAAACGATGA GTGCTAAGTGTTGGGAGGTTTCCGCCTCTCAGTGCTGCAGCTAACGCATTAAGCACT CCGCC (SEQ ID NO: 19) 1429R GCGGCTGGCTCCAAGGTTACCTCACCGACTTTGGGTGTTACAAACTCTCATGGTGTG ACGGGCGGTGTGTACAAGGCCCGGGAACGTATTCACCGCGGCGTGCTGATCCGCGA TTACTAGCGATTCCAGCTTCGTGTAGGCGAGTTGCAGCCTACAGTCCGAACTGAGAA CAGCTTTAAGAGATCCGCTTGCCTTCACAGGTTCGCTTCTCGTTGTACTGCCCATTGT AGCACGTGTGTAGCCCAGGTCATAAGGGGCATGATGACTTGACGTCATCCCCACCTT CCTCCGGTTTGTCACCGGCAGTCTCAATAGAGTGCCCAACTTAATGCTGGCAACTAT TAACAAGGGTTGCGCTCGTTGCGGGACTTAACCCAACATCTCACGACACGAGCTGA CGACAGCCATGCACCACCTGTCTCTTTGTCCCCGAAGGGAAAACCTAATCTCTTAGG TGGTCAAAGGATGTCAAGACCTGGTAAGGTTCTTCGCGTTGCTTCGAATTAAACCAC ATGCTCCACCGCTTGTGCGGGCCCCCGTCAATTCCTTTGAGTTTCAACCTTGCGGTCG TACTCCCCAGGCGGAGTGCTTAATGCGTTAGCTGCAGCACTGAGAGGCGGAAACCT CCCAACACTTAGCACTCATCGTTTACGGCATGGACTACCAGGGTATCTAATCCTGTT CGCTACCCATGCTTTCGAGCCTCAGCGTCAGTTACAGACCAGAGAGCCGCCTTCGCC ACTGGTGTTCTTCCATATATCTACGCATTCCACCGCTACACATGGAGTTCCACTCTCC TCTTCTGCACTCAAGATTGACAGTTTCTGATGCAGTTCTTCGGTTGAGCCGAAGGCTT TCACATCAGACTTATCAATCCGCCTGCGCTCGCTTTACGCCC (SEQ ID NO: 20) L. gasseri BWH #117427 27F ATACcTGCAGTCGAGCGAGCTTGCCTAGATGAATTTGGTGCTTGCACCAgATGAAAC TaGATACAAGCGAGCGGCGGACGGGTGAGTAACACGTGGGTAACCTGCCCAAGAGA CTGGGATAACACCTGGAAACAGATGCTAATACCGGATAACAACACTAGACGCATGT CTAGAGTTTAAAAGATGGTTCTGCTATCACTCTTGGATGGACCTGCGGTGCATTAGC TAGTTGGTAAGGCAACGGCTTACCAAGGCAATGATGCATAGCCGAGTTGAGAGACT GATCGGCCACATTGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAG GGAATCTTCCACAATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAG GGTTTCGGCTCGTAAAGCTCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGC CTTTATTTGACGGTAATTACTTAGAAAGTCACGGCTAACTACgTGC (SEQ ID NO: 21) 529R TAGTATTACCGTCAATAAAGGCCAGTTACTACCTCTATCTTTCTTCACTACCAACAGA GCTTTACGAGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGT CCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGT CCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGCATCATTGCCTTGGTAAGCCG TTGCCTTACCAACTAGCTAATGCACCGCAGGTCCATCCAAGAGTGATAGCAGAACC ATCTTTTAAACTCTAGACATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCC AGGTGTTATCCCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGC TCGCTTGTATCTAGTTTCATcTGGTGCAAGCACCAAATTCATCTAGGCAAGCTCGCTC GACTTGCATGTATTAGGCACGCCGCCAGCGTTCGTCCTGA (SEQ ID NO: 22) L. gasseri BWH #217213 27F ATAccTGCAGTCGAGCGAGCTTGCCTAGATGAATTTGGTGCTTGCACCAAATGAAAC TAGATACAAGCGAGCGGCGGACGGGTGAGTAACACGTGGGTAACCTGCCCAAGAGA CTGGGATAACACCTGGAAACAGATGCTAATACCGGATAACAACACTAGACGCATGT CTAGAGTTTAAAAGATGGTTCTGCTATCACTCTTGGATGGACCTGCGGTGCATTAGC TAGTTGGTAAGGTAACGGCTTACCAAGGCAATGATGCATAGCCGAGTTGAGAGACT GATCGGCCACATTGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAG GGAATCTTCCACAATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAG GGTTTCGGCTCGTAAAGCTCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGC CTTTATTTGACGGTAATTACTTAGAAAGTCACGGCTAACTACGTGCCA (SEQ ID NO: 23) 529R CTAGTATTACCGTCAATAAAGGCCAGTTACTACCTCTATCTTTCTTCACTACCAACAG AGCTTTACGAGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCG TCCATTGTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGT CCCAATGTGGCCGATCAGTCTCTCAACTCGGCTATGCATCATTGCCTTGGTAAGCCG TTACCTTACCAACTAGCTAATGCACCGCAGGTCCATCCAAGAGTGATAGCAGAACC ATCTTTTAAACTCTAGACATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCC AGGTGTTATCCCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGC TCGCTTGTATCTAGTTTCATTTGGTGCAAGCACCAAATTCATCTAGGCAAGCTCGCTC GACTTGCATGTATTAGGCACGCCGCCAGCGTTCGTCCTGA (SEQ ID NO: 24) L. crispatus ATCC #3820 27F GCGAGCGGAcTAACAGATTTACTTCGGTAATGACGTTAGGAAAGCGAGCGGCGGAT GGGTGAGTAACACGTGGGGAACCTGCCCCATAGTCTGGGATACCACTTGGAAACAG GTGCTAATACCGGATAAGAAAGCAGATCGCATGATCAGCTTTTAAAAGGCGGCGTA AGCTGTCGCTATGGGATGGCCCCGCGGTGCATTAGCTAGTTGGTAAGGTAAAGGCTT ACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACATTGGGACTGA GACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGC AAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGCTCT GTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGGTAATCAACC AGAAAGTCACGGCTAACTACGTGCCAGCAGCCGCGGTAATACGTAGGTGGCAAGCG TTGTCCGGATTTATTGGGCGTAAAGCGAGCGCAGGCGGAAGAATAAGTCTGATGTG AAAGCCCTCGGCTTAACCGAGGAACTGCATCGGAAACTGTTTTTCTTGAGTGCAGAA GAcGAGAGTGGAACTCCATGTGTAGCGGTGGAATGCGTAGATATATGGAAGAACAC CAGTGGCGAAgGCGGCTCTCTGGTCTGCAACTGACGCTGAGGCTCGAAAGCATGGGT AGCGAACAGGATTAGATACCCTGGTAGTCCATGCCGTAAACGATGAgTGCTAAGTGT TGGGAGG (SEQ ID NO: 25) 1429R GGTTAGGCCACCGGCTTTGGGCATTGCAGACTCCCATGGTGTGACGGGCGGTGTGTA CAAGGCCCGGGAACGTATTCACCGCGGCGTGCTGATCCGCGATTACTAGCGATTCCA GCTTCGTGCAGTCGAGTTGCAGACTGCAGTCCGAACTGAGAACAGCTTTCAGAGATT CGCTTGCCTTCGCAGGCTCGCTTCTCGTTGTACTGCCCATTGTAGCACGTGTGTAGCC CAGGTCATAAGGGGCATGATGACTTGACGTCATCCCCACCTTCCTCCGGTTTGTCAC CGGCAGTCTCATTAGAGTGCCCAACTTAATGCTGGCAACTAATAACAAGGGTTGCGC TCGTTGCGGGACTTAACCCAACATCTCACGACACGAGCTGACGACAGCCATGCACC ACCTGTCTTAGCGTCCCCGAAGGGAACTTTGTATCTCTACAAATGGCACTAGATGTC AAGACCTGGTAAGGTTCTTCGCGTTGCTTCGAATTAAACCACATGCTCCACCGCTTG TGCGGGCCCCCGTCAATTCCTTTGAGTTTCAACCTTGCGGTCGTACTCCCCAGGCGG AGTGCTTAATGCGTTAGCTGCAGCACTGAGAGGCGGAAACCTCCCAACACTTAGCA CTCATCGTTTACGGCATGGACTACCAGGGTATCTAATCCTGTTCGCTACCCATGCTTT CGAGCCTCAGCGTCAGTTGCAGACCAGAGAGCCGCCTTCGCCACTGGTGTTCTTCCA TATATCTACGCATTCCACGCTACACATGGAGTTCCACTCTCCTCTTCTGCACTCAAGA AAAACAGTTTCCGATGCAGTTCCTCGGTTAAGCCGAGGGCTTTCACATCAAACTTAT TCTTCCGCCTGCGCTCGCTTTACGCCCAATAAATCCGGA (SEQ ID NO: 26) L. crispatus Sh. Hillier 27F TGCAGTCGAGCGAGCGGACTAACAGATTTACTTCGGTAATGACGTTAGGAAAGCGA GCGGCGGATGGGTGAGTAACACGTGGGGAACCTGCCCCATAGTCTGGGATACCACT TGGAAACAGGTGCTAATACCGGATAAGAAAGCAGATCGCATGATCAGCTTTTAAAA GGCGGCGTAAGCTGTCGCTATGGGATGGCCCCGCGGTGCATTAGCTAGTTGGTAAG GTAAAGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACA TTGGGACTGAGACACGGCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCAGCAGCCGCGGTAATACGTAGG TGGCAAGCGTTGTCCGGATTTATTGGGCGTAAAGCGAGCGCAGGCGGAAGAATAAG TCTGATGTGAAAGCCCTCGGCTTAACCGAGGAACTGCATCGGAAACTGTTTTTCTTG AGTGCAGAAGAGGAGAGTGGAACTCCATGTGCTCTCTGGTCTGCAACTGACGCTGA GGCTCGAAAGCATGGGTAGCGAACAGGATAGATACCCTGGTAGTCCATGCCGTAAA CGATGAGTGCTAAGTGTTGGGAGGTTTCCGCCTCTCAGTGCTGCAGCTAACGCATTA AGCACTCCGCCGGGGGAGTACGACCGC (SEQ ID NO: 27) 1429R AAGGTTAGGCCACCGGCTTTGGGCATTGCAGACTCCCATGGTGTGACGGGCGGTGTG TACAAGGCCCGGGAACGTATTCACCGCGGCGTGCTGATCCGCGATTACTAGCGATTC CAGCTTCGTGCAGTCGAGTTGCAGACTGCAGTCCGAACTGAGAACAGCTTTCAGAG ATTCGCTTGCCTTCGCAGGCTCGCTTCTCGTTGTACTGCCCATTGTAGCACGTGTGTA GCCCAGGTCATAAGGGGCATGATGACTTGACGTCATCCCCACCTTCCTCCGGTTTGT CACCGGCAGTCTCATTAGAGTGCCCAACTTAATGCTGGCAACTAATAACAAGGGTTG CGCTCGTTGCGCTGTCTTAGCGTCCCCGAAGGGAACTTTGTATCTCTACAAATGGCA CTAGATGTCAAGACCTGGTAAGGTTCTTCGCGTTGCTTCGAATTAAACCACATGCTC CACCGCTTGTGCGGGCCCCCGTCAATTCCTTTGAGTTTCAACCTTGCGGTCGTACTCC CCAGGCGGAGTGCTTAATGCGTTAGCTGCAGCACTGAGAGGCGGAAACCTCCCAAC ACTTAGCACTCATCGTTTACGGCATGGACTACCAGGGTATCTAATCCTGTTCGCTAC CCATGCTTTCGAGCCTCAGCGTCAGTTGCAGACCAGAGAGCCGCCTTCGCCACTGGT GTTCTTCCATATATCTACGCATTCCACCGCTACACATGGAGTTCCACTCTCCTCTTCT GCACTCAAGAAAAACAGTTTCCGATGCAGTTCCTCGGTTAAGCCGAGGGCTTTCACA TCAGACTTATTCTTCCGCCTGCGCTCGCTTTACGCCCAATAAATCCGGACAACG (SEQ ID NO: 28) L. crispatus BWH #101211 27F TATGGgATGGCCCCGCGGTGCaTTAACTAgTTGGTAAGGTAAAGGCTTACCAAGGCG ATGATGCATAgCCgAGTTGAGAGACTGATCGGCCACATTGGGACTGAGACACGGCCC AAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGCAAGTCTGATG GAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGTAAAGCTCTGTTGTTGGTGA AGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGGTAATCAACCAGAAAGTCAC GGCTAACTACGTGCCAGCAGCCGCGGTAATACGTAGGTGGCAAGCGTTGTCCGGAT TTATTGGGCGTAAAGCGAGCGCAGGCGGAAGAATAAGTCTGATGTGAAAGCCCTCG GCTTAACCGAGGAACTGCATCGGAAACTGTTTTTCTTGAGTGCAGAAGAgGAGAGTG GAACTCCATGTGTAGCGGTGGAATGCGTAGATATATGGAAgAACACCAGTGGCGAag gCGGCTCTCTGGTCTGCAACTGACGCTGAGGCTCGAAAGCATGGGTAGCGAa (SEQ ID NO: 29) 1429R GACTTGatGtCATCCCCaCCTTCCtCCGGtTtGtCACCggcaGTCTCATTAgAGTGCCCAACT TAATGCTGGcAACtAAtAACAAGGGTTGCGCTCGTTGCGGGACTTAACCCAACATCTC ACGACACgAGCTGACGACAGCCATGCACCACCTGTCTTAgCGTCCCCGAAGGgAAcTT TGTATCTCTACaAATGGCACTAGATGTCAAGACCTGGTAAGGTTCTTCGCGTTGCTTC GAATTAAACCACATGCTCCACCGCTTGTGCGGGCCCCCGTCAATTCCTTTGAGTTTC AACCTTGCGGTCGTACTCCCCAgGCGGAgTGCTTAaTGCGTTAGCTGCAGCACTGAGa GGCgGAAACCTCCcaACACTTAGCACTCATCG (SEQ ID NO: 30)

APPENDIX B Vaginal Lactobacillus strain candidates contemplated to be beneficial in a medicinal bacterial mix (good clinical phenotype, term pregnancy): Primer sequences 1) 27F: AGA GTT TGA TCM TGG CTC AG (SEQ ID NO: 49) 2) 1492R: CGG TTA CCT TGT TAC GAC TT (SEQ ID NO: 50) 3) 529R: CGC GGC TGC TGG CAC (SEQ ID NO: 51) L. crispatus BWH #24629 27F ATCgCATGATCAGgTTTTAaaaaGaaGcgTAaGCTGTCgCTATGGGATGGCCCCGCGGTGC ATTAACTAGTTGGTAAGGTAAAGGCTTACCAAGGCGATGATGCATAGCCGAGTTGA GAGACTGATCGGCCACATTGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAG CAGTAGGGAATCTTCCACAATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTG AAGAAGGTTTTCGGATCGTAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTA ACTGGCCTTTATTTGACGGTAATCAACCAGAAAGTCACGGCTAACTACGTGCCAGCA GCCGCGGTAATACGTAGGTGGCAAGCGTTGTCCGGATTTATTGGGCGTAAAGCGAG CGCAGGCGGAAGAaTAAGTCTGATGTGAAAGCCCTCGGCTTAACCGAGGAACTGCA TCGGAAACTGTTTTTCTTGAGTGCAGAAGAaGAgAGTGGAACTCCATGTGTAGCGGT GGAATGCGTAgATATATGGAAGAAcACCAGTGgcGAAaGGcGGCTCTCTGGTCTGCAA CTGAcGCTGAGGCTCGAAAGCATGGGTAGCGAACAGGATTAaATACCcTGG (SEQ ID NO: 31) 1429R GAtGACTTGtcGTCaTCCCCACCTtCCtCCGGtTtGacAcCgGcaGTCTCATTAgAGTGCCCAA CTTAATGCTGGcAACTAATAACAAGGGTTGCGCTCGTTGCGGGACTTAACCCAACAT CTCACGACACGAGCTGACGACAGCCATGCACCACCTGTCTTAGCGTCCCCGAAGGG AACTTTGTATCTCTACAAATGGCACTAGATGTCAAGACCTGGTAAGGTTCTTCGCGT TGCTTCGAATTAAACCACATGCTCCACCGCTTGTGCGGGCCCCCGTCAATTCCTTTG AGTTTCAACCTTGCGGTCGTACTCCCCAGGCGGAgTGCTTAATGCGTTAGCTGCAGC ACTGAGAGGCGGAAACCTCCCAACACTTAGCACTCATCGTTTACGGCATGGACTACC AgGGTATCTAATCCTGTTCGCTACCCATGCTTTCGAGCCTCAGCGTCAGTTGCAGAcC AGAGAGCCGCCtTCGCCACTGGTGTTCTtCCATATATCTACGCATTCCACCGCTACAC ATGGAGTTccAcTCTCCTCTTCTGCACTCAAaAAAAACAGTTTcCGATGCAGTTCCTCG GTTAAccCaAGGGCTTTcACATCAaAcT (SEQ ID NO: 32) L. jensenii BWH #2054211 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCA (SEQ ID NO: 33) 529R CGTCaATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGA TCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTGG AAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTG GCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTAC CAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAA ACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTAT CCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTA TCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTAG GCACGCCGCCAGCGTTCGTCCTGA (SEQ ID NO: 34) L. jensenii BWH #285216 27F TGCAGTCGAGCGAGCTTGCCTATAGAAGTTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGAAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTAC (SEQ ID NO: 35) 529R CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACG ATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTTCGTCCATTGTGG AAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTG GCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTAC CAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAA ACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTAT CCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTA TCTATGTCCATTCCGAAGAACTTCTATAGGCAAGCTCGCTCGACTTGCATGTATTAG GCACGCCGCCAGCGTTC (SEQ ID NO: 36) L. jensenii BWH #174825 27F GCTTGCCTATAGAAGTTCTTCGGAATGGACATAGATACAAGCTAGCGGCGGATGGG TGaGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTTGGAAACAGATGC TAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAGGCGGCGTAAGCT GTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGGTAACGGCTTACCA AGGCGATGATGCATAGCtgagtTGAGAGACTGATCGGCCACATTGGGACTGAGACACG GCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGACGAAAGTCT GATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGaTCGTAAAGCTCTGTTGTTG GTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGGTAATCAACCAGAAAG TCACGGCTAACTACGTGCC (SEQ ID NO: 37) 529R ATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGATCCG AAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTTCGTCCATTGTGGAAGA TTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTGGCCG ATCAGTCTCTCAACTCaGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTACCAACT AGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAAACTTCT TTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTATCCCAGA CTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTATCTATG TCCATTCCGAAGAACTTCTATAGGCAAGCTCGCTCGACTTGCATGTATTAGGCACGC CGCCAGCGTTCGTCCTGAGC (SEQ ID NO: 38) L. jensenii BWH #171928 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTACGTGCCA (SEQ ID NO: 39) 529R CGTCAATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACG ATCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTG GAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGT GGCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTA CCAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTA AACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTA TCCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGT ATCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTA GGCACGCCGCCAGCGTTCGTCCTGAGCC (SEQ ID NO: 40) L. jensenii BWH #22731 27F TGCAGTCGAGCGAGCTTGCCTATTGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACGGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACAT TGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCAC AATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCG TAAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGG TAATCAACCAGAAAGTCACGGCTAACTAC (SEQ ID NO: 41) 529R CGTCaATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGA TCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTGG AAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTG GCCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCCGTTACCTTAC CAACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAA ACTTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTAT CCCAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTA TCTATGTCCATTCCGAAGAATTTCAATAGGCAAGCTCGCTCGACTTGCATGTATTAG GCACGCCGCCAGCGTTCGTCCTGA (SEQ ID NO: 42) L. jensenii BWH #220613 27F TGCAGTCGAGCGAGCTTGCCTATAGAAATTCTTCGGAATGGACATAGATACAAGCTA GCGGCGGATGGGTGAGTAACGCGTGGGTAACCTGCCCTTAAGTCTGGGATACCATTT GGAAACAGATGCTAATACCGGATAAAAGCTACTTTCGCATGAAAGAAGTTTAAAAG GCGGCGTAAGCTGTCGCTAAAGGATGGACCTGCGATGCATTAGCTAGTTGGTAAGG TAACgGCTTACCAAGGCGATGATGCATAGCCGAGTTGAGAGACTGATCGGCCACATT GGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACA ATGGACGAAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGTTTTCGGATCGT AAAGCTCTGTTGTTGGTGAAGAAGGATAGAGGTAGTAACTGGCCTTTATTTGACGGT AATCAACCAGAAAGTCACGGCTAACTACGTGCCAGCAG (SEQ ID NO: 43) 529R CGTCaATAAAGGCCAGTTACTACCTCTATCCTTCTTCACCAACAACAGAGCTTTACGA TCCGAAAACCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTTCGTCCATTGTGGA AGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGTGG CCGATCAGTCTCTCAACTCGGCTATGCATCATCGCCTTGGTAAGCcGTTACCTTACCA ACTAGCTAATGCATCGCAGGTCCATCCTTTAGCGACAGCTTACGCCGCCTTTTAAAC TTCTTTCATGCGAAAGTAGCTTTTATCCGGTATTAGCATCTGTTTCCAAATGGTATCC CAGACTTAAGGGCAGGTTACCCACGCGTTACTCACCCATCCGCCGCTAGCTTGTATC TATGTCCATTCCGAAGAATTTCTATAGGCAAGCTCGCTCGACTTGCATGTATTAGGC ACGCCGCCAGCGT (SEQ ID NO: 44) L. gasseri BWH #192712 27F GAGCTTGCCTAGATGAATTTGGTGCTTGCACCAAATGAAACTAGATACAAGCGAGC GGCGGACGGGTGAGTAACACGTGGGTAACCTGCCCAagAgACTGGGATAACACCTGG AAACAGATGCTAATACCGGATAACAACACTAGACGCATGTCTAGAGTTTAAAAGAT GGTTCTGCTATCACTCTTGGATGGACCTGCGGTGCATTAGCTAGTTGGTAAGGTAAC GGCTTACCAAGGCAATGATGCATAGCCgAgttGAGAGACTGATCGGCCACATTGGGAC TGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAATCTTCCACAATGGA CGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGGTTTCGGCTCGTAAAGC TCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGCCTTTATTTGACGGTAATTA CTTAGAAgGTCACGGCTAACTACGTGCCA (SEQ ID NO: 45) 529R ACCGTCNATAAaGGCCaGTTACTACCTCTATCTTTCTTCaCTACCAACAGAGCTTTACG AGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATTGTG GAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAATGT GGCCGATCAGTCTCTCAACTCGGCTATGCATCATTGCCTTGGTAAGCCGTTACCTTAC CAACTAGCTAATGCACCGCAGGTCCATCCAAGAGTGATAGCAGAACCATCTTTTAAA CTCTAGACATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCCAGGTGTTATC CCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGCTCGCTTGTATC TAGTTTCATTTGGTGCAAGCACCAAATTCATCTAGGCAAGCTCGCTCGACTTGCATG TATTAGGCaCgCCGCC (SEQ ID NO: 46) L. gasseri BWH #203326 27F TGCAGTCGAGCGAGCTTGCCTAGATGAATTTGGTGCTTGCACCAAATGAAACTAGAT ACAAGCGAGCGGCGGACGGGTGAGTAACACGTGGGTAACCTGCCCAAGAGACTGG GATAACACCTGGAAACAGATGCTAATACCGGATAACAACACTAGACGCATGTCTAG AGTTTAAAAGATGGTTCTGCTATCACTCTTGGATGGACCTGCGGTGCATTAGCTAGT TGGTAAGGCAACGGCTTACCAAGGCAATGATGCATAGCCGAGTTGAGAGACTGATC GGCCACATTGGGACTGAGACACGGCCCAAACTCCTACGGGAGGCAGCAGTAGGGAA TCTTCCACAATGGACGCAAGTCTGATGGAGCAACGCCGCGTGAGTGAAGAAGGGTT TCGGCTCGTAAAGCTCTGTTGGTAGTGAAGAAAGATAGAGGTAGTAACTGGCCTTTA TTTGACGGTAATTACTTAGAAAGTCACGGCTaACTACGTGCCAGCAGCC (SEQ ID NO: 47) 529R TATTACCGTCaaTAaGGCCAGTTACTACCTCTATCTTTCTTCaCTACCAACAGAGCTTT ACGAGCCGAAACCCTTCTTCACTCACGCGGCGTTGCTCCATCAGACTTGCGTCCATT GTGGAAGATTCCCTACTGCTGCCTCCCGTAGGAGTTTGGGCCGTGTCTCAGTCCCAA TGTGGCCGATCAgTCTCTCAACTCGGCTATGCATCATTGCCTTGGTAAGCCGTTGCCT TACCAACTAGCTAATGCACCGCAGGTCCATCCAAGAGTGATAGCAgAACCATCTTTT AAACTCTAGACATGCGTCTAGTGTTGTTATCCGGTATTAGCATCTGTTTCCAGGTGTT ATCCCAGTCTCTTGGGCAGGTTACCCACGTGTTACTCACCCGTCCGCCGCTCGCTTGT ATCTAGTTTCATTTGGTGCAAGCACCAaATTCATCTAggCAAGCTCGCTCGACTTGCA TGtATTAGGcacgcCGCC (SEQ ID NO: 48)

APPENDIX C Phenotypic Characteristics of strains L. gasseri 29313, L. crispatus 223310, L. jensenii 2054210 L. gasseri293-13/L. acidphilus 239-13 L. jensenii 2054210 L. crispatus 223310 ATCC SD-7101 ATCC SD-7102 ATCC S-6994; SD-7100 Rapid ANA II System (R8311002) - Remel Inc., Lenexa KS Hydrolysis of the following Urea Negative Negative Negative Beta-D-disaccharide Negative Negative Negative Alpha-L-arabinoside Negative Negative Negative Beta-D-galactoside Negative Negative Negative Alpha-D-glucoside Positive Positive Positive Beta-D-glucoside Positive Positive Positive Alpha-D-galactoside Negative Negative Negative Alpha-L-fucoside Negative Negative Negative Beta-D-glucosaminide Positive Negative Negative Phosphate Negative Negative Negative Leucyl-glycine Positive Positive Positive Glycine Positive Positive Positive Proline Positive Positive Negative Phenylalanine Positive Positive Positive Arginine Positive Positive Positive Serine Positive Positive Positive Pyrrolidonyl Positive Negative Negative Formation of Indole Negative Negative Negative PRAS - Anaerobe Systems, Morgan Hill CA Fermentation of the following Arabinose Negative Negative Negative Cellobiose Positive Positive Positive Esculin Positive Weak Positive Esculin hydrolysis Positive Positive Positive Glucose Positive Positive Positive Lactose Positive Negative Positive Maltose Positive Positive Positive Mannitol Negative Negative Negative Mannose Positive Positive Positive Raffinose Negative Positive Positive Rhamnose Negative Negative Negative Salicin Positive Positive Positive Sucrose Positive Positive Positive Trehalose Positive Positive Positive Xylose Negative Negative Negative Maldi-TOF Mass Spectrometry (Biomerieux Inc., Durham, NC) L. gasseri 50% L. jensenii 99.9% L. crispatus 99.9% L. acidophilus 50% 

What is claimed is:
 1. A composition for promoting a healthy human vaginal microbiota balance, the composition comprising a mixture of viable bacteria consisting of Lactobacillus crispatus, Lactobacillus jensenii, and Lactobacillus gasseri, wherein the bacterial mixture is comprised of: a. 66.7% Lactobacillus crispatus, 16.7% Lactobacillus jensenii, and 16.7% Lactobacillus gasseri; b. 50% Lactobacillus crispatus, 33.4% Lactobacillus jensenii, and 16.7% Lactobacillus gasseri; c. 50% Lactobacillus crispatus, 16.7% Lactobacillus jensenii, and 33.4% Lactobacillus gasseri; d. 73.3% Lactobacillus crispatus, 6.7% Lactobacillus jensenii, and 20% Lactobacillus gasseri; e. 50-73.3% Lactobacillus crispatus; or f. 16.7-33.4% Lactobacillus gasseri; and wherein the mixture of viable bacteria is in a glassy matrix.
 2. The composition of claim 1, further comprising an agent that promotes bacterial growth, a low pH buffering agent, a prebiotic, an anti-microbial agent/preparation, 9-(2-deoxy-2-fluoro-β-Darabinofuranosyl) adenine (WF-50), at least one antibiotic, or at least one excipient.
 3. The composition of claim 2, wherein the low pH buffering agent is boric acid, lactic acid, or ascorbic acid.
 4. The composition of claim 2, wherein the prebiotic is sucrose.
 5. The composition of claim 2, wherein the anti-microbial preparation comprises recombinant human soluble serine protease inhibitor (SLPI).
 6. The composition of claim 2, wherein the at least one antibiotic is metronidazole or clindamycin.
 7. The composition of claim 1, formulated for vaginal, oral, topical, or rectal delivery.
 8. The composition of claim 2, wherein the at least one excipient comprises a nonreducing monosaccharide, sugar alcohol, oligosaccharide, amino acid, polyvinylpyrrolodone, polyethylene glycol, Ficol, inulin, albumin, gelatin, whey proteins, and/or a polaxomer.
 9. The composition of claim 1, wherein the composition is stable at room temperature for at least one year when preserved by PBV.
 10. A composition for promoting a healthy human vaginal microbiota balance, the composition comprising a mixture of viable bacteria comprising: Lactobacillus crispatus strain 223310 identified by ATCC deposit PTA-127090; Lactobacillus jensenii strain 2054210 identified by ATCC deposit PTA-127092; and Lactobacillus gasseri strain is 29313 identified by ATCC deposit PIA-127091, and wherein the composition is formulated for vaginal, oral, or rectal delivery.
 11. The composition of claim 10, wherein the bacterial mixture is comprised of: a. 66.7% Lactobacillus crispatus, 16.7% Lactobacillus jensenii, and 16.7% Lactobacillus gasseri; b. 50% Lactobacillus crispatus, 33.4% Lactobacillus jensenii, and 16.7% Lactobacillus gasseri; c. 50% Lactobacillus crispatus, 16.7% Lactobacillus jensenii, and 33.4% Lactobacillus gasseri; d. 73.3% Lactobacillus crispatus, 6.7% Lactobacillus jensenii, and 20% Lactobacillus gasseri; e. 50-73.3% Lactobacillus crispatus; f. 6.67-33.4% Lactobacillus jensenii; or g. 16.7-33.4% Lactobacillus gasseri.
 12. The composition of claim 10, further comprising an agent that promotes bacterial growth, a low pH buffering agent, a prebiotic, an anti-microbial agent/preparation, 9-(2-deoxy-2-fluoro-β-Darabinofuranosyl) adenine (WF-50), at least one antibiotic, or at least one excipient.
 13. The composition of claim 10, wherein the bacteria are in dried form.
 14. The composition of claim 10, wherein the mixture of viable bacteria is in a glassy matrix.
 15. The composition of claim 10, wherein the composition is stable at room temperature for at least one year when preserved by PBV.
 16. A method of treating a vaginal or cervical infection, the method comprising administering a composition of claim 1 or claim 10 to a subject at risk or having vaginal dysbiosis.
 17. The method of claim 16, wherein the vaginal or cervical infection is: a. bacterial vaginosis; b. caused by the vaginal pathogen Trichomonas vaginalis; c. caused by the vaginal pathogen Gardnerella vaginalis; d. caused by the vaginal pathogen Prevotella bivia; or e. caused by the vaginal pathogen Atopobium vaginae.
 18. The method of claim 16, further comprising selecting a subject at risk for or having been identified as having a vaginal infection.
 19. The method of claim 16, wherein administering the composition restores a healthy vaginal flora.
 20. A method of maintaining, establishing, or restoring a human vaginal microbiota balance, the method comprising administering a composition of claim 1 or claim 10 to a human subject in need thereof. 